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Lymph-nodes and liver of splenectomized dogs receiving hemolytic serum and showing 
phagocytic cells containing red blood-corpuscles. 

Pagt 179 






EXPLANATION OF PLATE I. 

The drawings were made with the camera lucida and with a Spencer 
microscope, objective, 4 mm., ocular, 8. 

Figs. 1, 2, and 3 represent lesions in a dog that was splenectomized 
on March 11, 1912, received hemolytic serum on March 14, and died 
on March 15. The actual lapse of time was about thirty-six hours. 

Fig. 1. Peripheral sinus of a mesenteric lymph node containing 
large numbers of endothelial cells filled with red blood corpuscles and 
occasionally also polymorphonuclear leucocytes. 

Fig. 2. Similar cells in a central sinus of the same lymph node. 

Fig. 3. A section of liver with two Kupfer cells containing red 
blood corpuscles. 

Fig. 4. Similar to figure 3, but from a dog that was splenectomized 
on July 19, 1911, received hemolytic serum on March 8, 1912, and died 
after forty-eight hours. 



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THE 

SPLEEN AND ANAEMIA 

EXPERIMENTAL AND CLINICAL STUDIES 



BY 

RICHARD MILLS PEARCE, M.D., Sc.D. 

PROFESSOR OF RESEARCH MEDICINE 
WITH THE ASSISTANCE OF 

EDWARD BELL JOtUMBHAAR, M.D., Ph.D. 

ASSISTANT PROFESSOR OF RESEARCH MEDICINE 

AND 

CHARLES HARRISON FRAZIER, M.D., Sc.D. 

PROFESSOR OF CLINICAL SURGERY, UNIVERSITY OP PENNSYLVANIA 



16 ILLUSTRATIONS, COLOR AND BLACK AND WHITE. 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



& 



^ 






COPYRIGHT, 19 1 8, BT J. B. LIPPINCOTT COMPANY 



Eleetrotyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A. 



MR 15 1918 



©CI.A494076 
/Ha, 



TO THE LIBERAL AND FAR-SIGHTED BENEFACTOR 
WHO ESTABLISHED, UNDER THE CLOAK OF ANO- 
NYMITY, THE JOHN HERR MUSSER DEPARTMENT OF 
RESEARCH MEDICINE IN THE UNWERSITY OF PENN- 
SYLVANIA, THIS BOOK IS GRATEFULLY DEDICATED 



PREFACE 

In this volume splenectomy is considered, first, as a 
means of studying experimentally in animals the relation 
of the spleen to blood destruction and regeneration and, 
second, as a therapeutic procedure in the treatment of dis- 
eases of man accompanied by ansemia. No attempt is made 
to discuss injuries, infections and tumors of the spleen, or, 
except incidentally, the problems — leukocytosis and leu- 
caemia — of the white blood-cells. The emphasis is on the 
side of the red blood-cell and the relation of the spleen to 
the quantitative and qualitative changes which the red cell 
may undergo. 

The chapters on experimental and metabolic observa- 
tions are based on some twenty odd studies carried out 
during the past five years in the John Herr Musser Depart- 
ment of Research Medicine of the University of Penn- 
sylvania, and reported from time to time in medical period- 
icals, under the general title of " The Relation of the Spleen 
to Blood Destruction and Regeneration and to Hsemolytic 
Jaundice." These various papers have been rearranged 
and largely rewritten and brought into relation with the 
general literature so as to offer a consecutive comprehensive 
presentation of the general experimental problem. 

Such experimental studies are obviously of importance 
in connection with the diseases of man characterized by 
splenomegaly, with ansemia or jaundice, or both, and in 
connection with which splenectomy, as a therapeutic pro- 
cedure, has recently been so widely tried. Clinical studies 
of the splenomegalies and of the results of splenectomy in 
man are therefore presented by Dr. Krumbhaar. These 
chapters bring into one volume for the first time the modern 



vi PREFACE 

views concerning the classification, diagnosis and treatment 
of the non-infectious splenomegalies characterized by blood 
destruction. The final section by Dr. Frazier gives details 
of the technic of the operation of splenectomy in man. This 
has been included, partly to complete our presentation, but 
chiefly to bring out new points concerning the operation 
which have been gained as the result of its widely extended 
use during the last few years. 

Acknowledgments are due, and are gratefully made, to 
those assistants, — J.H. Austin, M.D. ; Harry Dubin, Ph.D. ; 
A. B. Eisenbrey, M.D.; Samuel Goldschmidt, Ph.D.; 
H. T. Karsner, M.D.; E. B. Krumbhaar, M.D.; J. H. 
Musser, Jr., M.D.; M. M. Peet, M.D., and O. H. Perry 
Pepper, M.D., — who assisted in the experimental work and 
thus made possible the many detailed studies, and likewise 
to the Board of Scientific Directors of the Rockefeller In- 
stitute for Medical Research, who by grants of money from 
time to time furthered the distinctly laboratory studies. To 
the editors of the Journal of Experimental Medicine, 
Archives of Internal Medicine, American Journal of the 
Medical Sciences, The Journal of the American Medical 
Association and the New York Medical Journal, we are 
also indebted for the privilege of reproducing in the present 
form material originally appearing in their journals. 



The material presented under the headings of experi- 
mental and metabolic studies constitutes the substance of the 
Cartwright Lectures delivered in New York on October 24 
and 25, 1916, under the auspices of the Association of the 
Alumni of the College of Physicians and Surgeons of 
Columbia University. 

September, 1917. THE AUTHORS. 



CONTENTS 

PART I. 

Experimental Studies by R. M. Pearce. 

CHAPTER PAGE 

I. The History of Extirpation of the Spleen 3 

II. The Effect of Splenectomy in the Dog 11 

(1) The Anaemia, (2) The Increased Resistance of 
the Red Blood-cells, (3) The Decreased Tendency of 
Haemolytic Agents to Cause Haemogiobinuria and 
Jaundice. 

III. Concerning the Supposed Regulatory Influence 

of the Spleen in Blood Destruction and 
Regeneration 58 

A. In Relation to the Decreased Tendency to 
Hemoglobinuria and Jaundice: (1) The Relation 
of Spleen to the Liver and the Formation of Bile 
from Haemoglobin, (2) The Influence of the Course 
of the Blood to the Liver, (3) The Influence of 
Anaemia, (4) Influence of the Increased Resistance 
of the Red Cells, (5) Are Splenic Extracts Haemo- 
lytic? (6) Hemolytic Influence of Fatty Acids and 
Lipoids in Haemolysis. 

IV. Concerning the Supposed Regulatory Influence of 

the Spleen in Blood Destruction and Re- 
generation 87 

B. In Relation to Anaemia: (1) A Comparison of the 
Arterial and Venous Blood of the Spleen, (2) Influence 
of Splenic Extract upon Blood Formation, (3) Influ- 
ence of Feeding Spleen to Splenectomized Dogs, (4) 
The Repair of an Artificially Produced Anaemia in 
Splenectomized Animals, (5) The Influence of the 
Spleen upon Iron Metabolism. 

V. Control Experiments: The Diversion of the 
Splenic Blood from the Liver Without Re- 
moval of the Spleen 121 

vii 



viii CONTENTS 

(1) By Ligation of the Splenic Vein, (2) By Trans- 
plantation of the Splenic Vein into the Vena Cava, 
(3) By Eck Fistula. 
VI. The Changes in the Bone-marrow After Splenectomy 140 
(1) Discussion of the Literature, (2) Histological 
Studies of the Dog's Normal Marrow, (3) Changes 
After Splenectomy. 
VII. The Changes in the Liver and Lymph-nodes After 

Splenectomy 164 

Discussion of the Literature. Changes in Lymph- 
nodes. Phagocytosis of Red Cells by Endothelial 
Cells of Lymph-nodes and Liver. Microchemical 
Test for Iron in Lymph-nodes and Liver. 
VIII. Metabolism Studied on the Dog Before and After 

Splenectomy 181 

IX. General Summary of Experimental Studies 195 

X. Metabolism Studies on Man Before and After 

Splenectomy 202 

PART II 

Clinical Observations by E. B. Krumbhaar 
XL Classification and Analysis of Types of Spleno- 
megaly Accompanied by Anemia 241 

Splenic Anaemia, Gaucher 's Disease, Banti's Disease, 
Von Jaksch's Disease, Acquired and Congenital 
Hsemolytic Jaundice, Pernicious Anaemia. 
XII. Methods of Value in the Diagnosis and Prognosis 

of Splenic Disease 269 

XIII. Treatment of Splenic Diseases by Methods Other 

than Splenectomy 291 

XIV. Treatment: Value of Splenectomy as a Therapeutic 

Procedure 299 

PART III 

Surgical Observations by Charles H. Frazier 
XV. The Surgical Treatment of Lesions of the Spleen 333 

(1) Preparation of the Patient for Splenectomy 

(2) The Operation and (3) The After-care of the 
Patient. 

Bibliography 359 



ILLUSTRATIONS 

COLOR PLATES 

PLATE OPPOSITE PAGE 

I. Lymph-nodes and Liver of Splenectomized Dogs Receiv- 
ing Hemolytic Serum and Showing Phagocytic Cells 

Containing Red Blood-corpuscles Frontispiece 

II. Histology of Gaucher's Disease. Alveolar Arrangement 

of Large Vesicular Cells with Small Concentric Nuclei 245 

ILT. Spleen of Banti's Disease 248 ' 

IV. Histology of Spleen of Early Banti's Disease 250 

V. Histology of Spleen of Late Banti's Disease 252 v 

VI. Histology of Spleen of Congenital Hemolytic Icterus. . . 252 

VII. Spleen of Pernicious Anaemia 265 v 

VIII. Test for Resistance of Erythrocytes. Salt Solution (Nace) 

Varying in Strength from 0.3 to 0.5 Per Cent 267 v 

IX. Reticulated Red Blood-cells. From a Case of Hemolytic 

Jaundice 276 

X. The Relationship of the Tail of the Pancreas to the 

Posterior Aspect of the Pedicle 346 

XI. The Peritoneal Prolongation Between the Spleen and the 
Splenic Flexure of the Colon, Which Must be Divided 
Before the Organ Can be Completely Mobilized. . . . 347 

XII. Left-side Bevan Incision for Splenectomy 350 • 

Xni. First Step in the Mobilization of the Spleen 352 

XIV. To Control Bleeding After Mobilization of the Spleen a 
Large Tampon of Gauze, Wrung out in Hot Water, 

is Introduced into the Left Hypochondrium 352 

XV. Fractional Ligation After Isolation of the Vessels of the 
Pedicle by Blunt Removal of Fat and Connective 

Tissue 353 

XVI. The Double-clamp Method of Dealing with the Pedicles 353 

ix 



ILLUSTRATIONS 



TEXT CUTS 



1. Composite Curve of the Red Blood-cell Count of Seven Dogs 

After Splenectomy 13 

2. Composite Curve of the Haemoglobin Estimation of Seven 

Dogs After Splenectomy 15 • 

3. Composite Curve of the Leucocyte Counts of Five Dogs After 

Splenectomy 18 



PARTI 

EXPERIMENTAL STUDIES BY R. M. PEARCE 



THE SPLEEN AND ANAEMIA 

CHAPTER I 
THE HISTORY OF EXTIRPATION OF THE SPLEEN 

The statement is frequently seen that the ancients 
practised removal of the spleen in the belief that it 
improved the wind of runners. It is also stated in the 
older literature that the swift giraffe is spleenless, an 
erroneous supposition that may have had something to do 
with the views of the ancients concerning the spleen and 
the speed of runners. Aristotle 21 assumed that the spleen 
is not necessary for the maintenance of existence, and 
Erasistratus insisted that it is of no use whatever. Galen 
more conservatively considered it an organ full of mys- 
tery (Mysterii pleni organon) and that it probably 
removed the melancholy of the blood going from the liver 
to the stomach. The first positive statement as to its 
extirpation (not excision) is made in Pliny's 357 Natural 
History. An old English 357 translation runs as follows : 
" This member (the spleen) hath a propriete by itself e 
sometimes, to hinder a man's running; whereupon pro- 
fessed runners in the race that bee troubled with the splene, 
have a devise to burne and waste it with a hot yron. And 
no marveile; for why? They say that the splene may be 
taken out of the body by way of incision, and yet the crea- 
ture live neverthelesse ; but if it be man or woman that is 
thus cut for the splene, he or she looseth their laughter by 
the means. For sure it is that intemperate laughers have 
always great splenes." In connection with the last state- 

s 



4 THE SPLEEN AND ANAEMIA 

ment it is interesting that the modern German word for 
hypochondriasis is " Milzsucht." Pliny is said to have per- 
formed experiments involving the removal of the spleen 
from dogs, but this is probably merely an incorrect quota- 
tion of the foregoing. The belief that splenectomy im- 
proved the wind of runners was not lost sight of in the 
middle ages, as is shown by the couplet quoted by Brog- 
sitter 60 from Murer's Belagerung von Babylon: 

" Ich han mir Ion dass milz schnyden, 
Dass ich mag laufen wegt und veer." 

He also quotes Paracelsus, who considered the spleen 
" des Leibers und Lebens Unkraut," and advised phy- 
sicians to excise it whenever possible. Van Helmont, on 
the other hand, attributed to it important and even vital 
functions. 

The first authentic experimental splenectomy in the 
dog was performed by Zambeccari 482 in 1680, with appar- 
ently an uneventful recovery. Mar cello Malpighi, 272 the 
discoverer of the lymphoid follicles of the spleen, had pre- 
viously described the effects of ligating the splenic vessels 
of a dog. It not only quickly recovered from the opera- 
tion, with no noticeable injury to health, but became more 
voracious and much lazier and fatter. Nothing abnormal 
was noted in the stools. A second operation on this dog, 
performed some time later, showed almost complete dis- 
appearance of the spleen, but no other changes except 
slight enlargement of the liver and engorgement of the 
mesenteric vessels. Clarke 78 successfully extirpated a 
dog's spleen in 1676, and during the year following found 
no changes except that the animal became much fatter. 

The celebrated pathologist, Morgagni, 299 states that he 



EXTIRPATION OF THE SPLEEN 5 

and Vallisnerius found during a period of five years' study 
no change in the size, disposition, or fertility of dogs whose 
spleens had been removed. J. H. Schultze 8M early prac- 
tised splenectomy on dogs with a view to the application 
of the operation to human beings. Harvey and his pupils 
are frequently quoted as having extirpated the spleen in 
dogs, but we have not been able to find such accounts in 
Harvey's works. 

Observations on experimental splenectomy are more 
numerous in the nineteenth century. Assolant, 20 found 
that in dogs the blood became more watery, with the ap- 
pearance of scurvy-like symptoms and fatal peptic ulcer. 
He states that Dupuytren lost almost half of forty dogs 
after splenectomy. Those that survived recovered in two 
or three weeks and acquired abnormal appetites. Spitta 
and Mayo found increase in weight, and Mayer increased 
tendency to sleep. Saunders reported no change in bile 
formation. A. S. Schultze 3 " removed the spleen of 
twenty- four animals (dogs, cats, goats, rabbits), losing 
only one puppy. He states that the operation is followed 
by lessened fertility, greater inclination and ability to run 
far, and at first a decreased secretion of bile. Czermak, 85 
working with dogs, rabbits and cats, found that two-thirds 
of the animals survived, and showed lessened fertility and 
enlargement of the mesenteric lymph-nodes. He noted 
that the spleen became greatly congested after feeding. 
Vulpian, 459 on the other hand, found no change in fertility. 
Enlargement of the lymph-nodes after splenectomy was 
noted by Tiedemann and Gmelin, 434 Hyrtl, 192 Mayer, 280 
Fuhrer and Ludwig, 132 Eberhard, 100 and Simon. 409 

Mayer maintained also that the extirpated spleen was 



6 THE SPLEEN AND ANAEMIA 

easily replaced by a newly-formed organ. This was con- 
firmed by Eberhard, working on the frog, and by certain 
French and Italian investigators (Philippeaux, 350 Eter- 
nod, 107 Tizzoni, 437 ). More careful later work (Pey- 
rani, 348 Tizzoni, 438 Ceresole, 69 Tedeschi, 430 ), however, 
showed that when the spleen had been completely removed 
no regeneration took place; but, if a small portion was 
left in situ, it might hypertrophy and simulate complete 
regeneration ( Philippeaux, 351 Laudenbach 239 ) . Even 
this, however, has been denied by Peyrani 349 and Cere- 
sole. 69 Bardeleben 34 found that extirpation of both spleen 
and thyroid was almost invariably fatal. Mosser 302 noted 
a stimulation of the bone-marrow. 

Thus we find that before the year 1875 numerous 
experimenters, working on dogs, cats, goats, rats, mice, 
guinea-pigs, sheep, rabbits, frogs, and one (Eternod) on 
a fox, had found that the spleen was not necessary to 
life. Though one out of four splenectomized animals died 
(usually from peritonitis or pneumonia), the others 
quickly recovered and enjoyed good health. The most 
constant findings were increased appetite and eventual 
gain in weight. At autopsy, enlargement of the mesen- 
teric lymph-nodes was frequently found, with occasionally 
enlargement of the liver, congestion of the splanchnic ves- 
sels, and, according to Mosser and Schindler, 303 stimulation 
of the bone-marrow. The power to regenerate after extir- 
pation was denied, though it was shown that if small 
amounts of splenic tissue are left behind, these possess 
great capacity for hypertrophy. 

The first recorded splenectomy on a human being is 
the celebrated operation performed in Naples in 1549, by 
Zaccarelli, at the instance of Fioravanti, 117 whose descrip- 
tion follows: 



EXTIRPATION OF THE SPLEEN 7 

In the month of April I was called to a Greek woman, the wife 
of a Greek centurion, or war captain, who lived at Panormus, near the 
Garden of Marinus de Terra Nova. Her name was Maruella, and she 
was twenty-four years old. Her spleen was stopped up (oppilatus) 
and grew to such a size that the body could not have held a larger one. 
She had been visited by several doctors and had been told that if she 
wished to be cured it would be necessary to take the spleen out of the 
body. The captain himself came to me and took me with him to visit 
his wife; she desired of me the removal of the spleen. For this pur- 
pose I invited an old man named Adrian Zaccarelli, from the town 
of Palum, in the kingdom of Naples, who was very skilled in surgery. 
With him I proceeded to the operation. The old man made an incision 
in the body and immediately the spleen protruded from the body. 
After we had separated it from the membranes we pulled it entirely 
out and sewed the body up, leaving only a little hole (spiraculo exiguo 
relicto). This I cured with oleum hypericonis, incense powder, mastix, 
and so on. In this manner she was cured in twenty-four days. When 
taken out of the body the spleen weighed thirty-two ounces. 

It should be said that some writers have doubted the 
veracity of this description, and Simon has suggested that 
on account of the discrepancy in the size of the tumor 
before and after removal it may have been an ovarian cyst. 

Two other equally doubtful reports of successful sple- 
nectomy in the sixteenth century are at hand. Baillon 25 
tells in a few words how, in 1578, an unknown operator 
removed the spleen, 

" qui secuit prius superiore parte ligata; convaluit wger. Este 
igitur splentam necessarius? " (Which he cut after the upper portion 
had been tied; the sick man recovered. Is then the spleen so necessary 
to life?) 

Rousset 388 also describes the successful removal, 
by a certain Doctor Viard, of a spleen which had already 
protruded through a wound in the left side. 

In the seventeenth century two cases of total removal 



8 THE SPLEEN AND ANAEMIA 

of the spleen are recorded. Timothy Clarke's 78 case was 
reported by an eye-witness, Dr. Dovbeny Turbevile. A 
certain William Panier, of Somerset, in an attempted sui- 
cide drove his butcher's knife into his left side. The spleen, 
part of the omentum, and the intestines protruded from 
the wound, and his companions left him for dead. Three 
days later a surgeon replaced the intestines, cut away the 
spleen and omentum, and sewed up the wound. The 
patient quickly recovered, was quite well a year later, and 
then migrated to New England, where he lived happily 
and in good health for some years. The second case was 
of like character. Nicolaus Matthia, 279 the town surgeon 
of Colberg, in 1678, was sent by the magistrate to a neigh- 
boring town to see a young man who had been injured 
by a knif e-thrust in the left side of the abdomen. The pro- 
truding spleen was pulled entirely outside the body and 
ligated. Three days later the spleen was removed and the 
bleeding controlled with styptics. The patient recovered 
completely in three weeks, and six years later was in good 
health. 

Thus physicians began to realize that the spleen was 
not necessary for life. However, in spite of several simi- 
lar successful splenectomies in the eighteenth century 
(Gerbezius, 1700 ; 112 Ferrerius, 1711 ; 112 South- Wilson, 
1743 412 ), rest, diet, salves, and bloodletting were con- 
sidered the proper treatment for injuries of this important 
organ. The first case of extirpation of the spleen reported 
in America is apparently that of O'Brien, 319 in 1816, for 
prolapse following a knife- wound. The patient recovered 
completely in the space of eight weeks. 

Another proof that the spleen is not necessary for life 
is found in occasional reports of congenital absence of 



EXTIRPATION OF THE SPLEEN 9 

the spleen. In fact, these reports indicate that an indi- 
vidual may live to an advanced age and exhibit no abnor- 
mality traceable to the absence of the spleen. The case 
reported by Hodenpyl 181 exhibited a general lymphoid 
hyperplasia, and it is probable that, as after splenectomy 
there is a gradual adaptation of the blood-regulating 
organs, so also, in the congenital absence of the spleen, 
other organs may take on the function of the missing organ. 
Since the ten cases collected by Hodenpyl, other authentic 
cases have been reported by Kohlhass, 221 Sternberg, 410 and 
Riches, 373 making a total of 13. Unfortunately, modern 
methods of blood examination were not included in the 
study of any of these cases. 

Karl Quittenbaum, 368 who introduced the practice of 
ovariotomy into Germany, was probably the first to plan 
deliberate splenectomy for disease of the spleen. Xumer- 
ous successful splenectomies on dogs and cats led him to 
believe that the omentum, whose vessels were always en- 
larged, took over the function of the spleen. In 1826 he 
had occasion to practise the operation on a young woman 
in an advanced stage of hepatic cirrhosis. Though she 
suffered from extreme ascites and weakness, he yielded 
against his judgment to the patient's entreaties, and re- 
moved the spleen. She died six hours later from shock. 

More important in bringing the operation to the atten- 
tion of the medical world was another unsucessful opera- 
tion, by Kiichler 231 in 1855. Death occurred a few hours 
after operation, due to hemorrhage from a branch of the 
splenic artery that had not been ligated. This gave rise to 
a lengthy controversy between Kiichler and the Verein 
Hessischer Aerzte, represented by the surgeon, G. Simon. 
Efforts towards reconciliation by Adelmann, of the Uni- 



10 THE SPLEEN AND ANAEMIA 

versity of Dorpat, to whom the matter had been referred, 
were unsuccessful. On account of Simon's greater repu- 
tation, his opinion prevailed that the operation was justi- 
fiable only when necessitated by an otherwise fatal wound. 
Ten years elapsed before splenectomy was again reported, 
this time in England by Spencer Wells, 465 whose patient 
died one week after operation, probably from septicaemia. 
The nature of the enlargement of the spleen is not stated. 
In spite of the unsuccessful outcome of this case, attempts 
at splenectomy quickly became more numerous. Thus 
Schumann, 400 collected sixteen cases in 1868; Collier, 82 
twenty-nine in 1882, and Adelmann, 4 fifty-three in 1887. 
Since that date the literature on splenectomy has been very 
thoroughly covered by three authors, Vulpius 460 (to 1894) , 
Laspeyres 238 (1894 to 1903), and Michelsson 290 (1903 
to 1913) . These reports show that in later years the mor- 
tality after splenectomy has been materially reduced. This 
is due in part to improvement in technic and in part to the 
general abandonment of the operation in cases of leukae- 
mia, in which condition surgical interference is nearly 
always disastrous. For the simpler conditions, such as cyst, 
torsion, or wounds uncomplicated by copious hemorrhage, 
the mortality is almost nil. The recent applications of 
splenectomy to other conditions, as the anaemias, will be 
discussed in later chapters. 



CHAPTER II 

EXPERIMENTAL STUDIES 

THE EFFECTS OF SPLENECTOMY IN THE DOG 

(l)THE ANiEMIA, (2) THE INCREASED RESISTANCE 
OF THE RED BLOOD-CELLS, (3) THE DECREASED 
TENDENCY OF HEMOLYTIC AGENTS TO CAUSE 
HEMOGLOBINURIA AND JAUNDICE. 

The experimental studies here presented had for their 
object the attainment of new knowledge, and the con- 
firmation or otherwise of older views, concerning the effect 
produced on the blood by the absence of the spleen. All 
our experimental observations have been made upon the 
dog. 

The most important changes after splenectomy we have 
found to be (1) a varying degree of anaemia, (2) increased 
resistance of the erythrocytes, and (3) lessened tendency 
to jaundice when hemolytic agents are administered. Less 
frequent results which follow the procedure are: (4) de- 
struction of erythrocytes by the endothelial cells of the 
lymph-nodes and the liver, and (5) transformation of the 
marrow of the long bones from a yellow to a red marrow. 
These several changes will be presented, so far as possible, 
in the order named, and in connection with them will be 
offered evidence concerning the relation of the spleen to 
protein, fat, and iron metabolism, and data on other minor 
phases of the general problem of the relation of the spleen 
to blood destruction and regeneration. As control studies, 
a series of observations are offered on the results of divert- 
ing the splenic blood from the liver without removal of 
the spleen. 

li 



12 



THE SPLEEN AND ANEMIA 



I. THE ANAEMIA FOLLOWING SPLENECTOMY 

This is of the type of the so-called secondary anaemia, 
characterized by a decrease in the number of red cells and 
the haemoglobin content, with little evidence at first of 
regenerative changes. In many instances the anaemia 309 
develops almost immediately and progresses gradually 
until about the end of the first month, when it reaches its 
point of greatest severity ; the return to normal then begins, 
and a blood condition similar to that before splenectomy 






TABLE I * f 
Red Cell Counts After Splenectomy 



Prelimi- 


Dog 32 


Dog 33 


Dog 41 


Dog 44 


Dog 46 


Dog 57 


Dog 59 


nary count 


5,340,000 


4,930,000 


5,350,000 


5,150,000 


5,520,000 


5,520,000 


4,610,000 


1* 


4,500,000 




4,540,000 


4,450,000 




5,100,000 


4,140,000 


3 


4,700,000 




4,710,000 


5,090,000 




5,120,000 


3,690,000 


5 


4,470,000 




4,700,000 


4,860,000 




5,125,000 


2,390,000 


7 


4,620,000 




4,070,000 


5,120,000 






3,120,000 


9 


4,800,000 




3,920,000 


5,060,000 




3,940,000 


3,960,000 


12 


4,610,000 




3,840,000 


4,310,000 


5,820,000 


3,810,000 


4,210,000 


15 


4,600,000 


5,980,000 


3,500,000 


3,720,000 


5,590,000 


4,280,000 




18 


3,900,000 




3,200,000 


3,500,000 


6,310,000 


4,440,000 


4,600,000 


21 








3,390,000 




4,390,000 




24 


3,550,000 




2,890,000 




5,760,000 


3,150,000 


4,460,000 


27 








3,220,000 


5,380,000 




3,560,000 


30 




4,790,000 


3,050,000 




5,280,000 


3,560,000 


4,120,000 


36 


3,720,000 






3,100,000 


4,960,000 


2,970,000 


4,510,000 


42 




3,550,000 


2,880,000 




4,580,000 


3,200,000 


4,010,000 


48 


3,970,000 


4,600,000 


3,010,000 


3,680,000 




4,100,000 


4,490,000 


54 


4,240,000 


5,020,000 


3,260,000 






4,210,000 


4,570,000 


60 




4,000,000 








4,740,000 




66 


4,890,000 


4,190,000 


3,980,000 


4,740,000 




5,010,000 


4,980,000 


72 




4,300,000 








4,680,000 


4,700,000 


80 


5,350,000 


3,680,000 


4,950,000 


4,740,000 




5,980,000 




88 




3,860,000 








5,320,000 


4,340,000 


96 




4,000,000 








5,480,000 


5,100,000 


104 


5,100,000 


4,200,000 


5,240,000 


4,500,000 






5,400,000 


124 


5,230,000 


4,340,000 


4,610,000 


4,150,000 




5,240,000 




150 




4,800,000 








5,216,000 


6,250,000 


240 


6,120,000 


5,184,000 


5,230,000 


4,460,000 




5,100,000 


5,550,000 


300 


15,350,000 


5,490,000 


4,970,000 




6,050,000 





* The figures in the first column refer to the number of days after splenectomy, 
t In this, as in subsequent tables of blood-cell counts, intervening counts that fail to add 
to the picture of the blood changes have been omitted. 



EXPERIMENTAL STUDIES 



13 



is reached after two and a half to three months. Rarely 
the onset 311 of the anaemia may be delayed, and not infre- 
quently the lowest point is not reached for six weeks, and 
the return to normal delayed until four, five, or six months, 
or occasionally until even longer periods. In some instances 
there is an actual rise of haemoglobin and red blood-cell 
count for several days after operation. This, however, is 
found after other operations of similar intensity and prob- 
ably has nothing to do with the removal of the spleen. 



Red 

B100CI 

Cells 


Before 
Splenec- 


After Splenectomy Time in Days 


tomy 


i 


3 


5 


7 


9 


12 


15 


18 


z\ 


Z4 


^7 


50 


3G 


42 


48 


54 


60 


'36 


12 


80 


88 


96 


[01 


Z4 


150 


m 


300 






















































r 


-+~ 




5.200,000 


\ 


















































/ 






5,000,000 


\ 
























































4,800,000 


_$ 












































r- 


~"s 


, 








4,600.000 




K 










































i 




•* 








4400,000 






\ 








y 


1 s 










































4.200,000 


















\ 








A. 








r' 


/ 






















4000,000 




















\ 




/ 


t V 


\ 






/ 
























3.800,000 




















V 








\ 




/ 


























3.S00O00 






























V 























































































Fig. 1. — Composite curve of the red blood-cell count of seven dogs after splenectomy. 

The figures of Table I show in general a prompt onset, 
a gradually increasing anaemia, and a slow return to nor- 
mal. An irregularity is seen in Dog 46, which failed to 
show a fall in the red cell count until one month had 
elapsed, and also in Dog 44, in which the normal level had 
not been reached after ten months. Certain minor fluctua- 
tions are evident here and there, but in general the anaemia 
takes a definite course. 

As a rule, the decrease in haemoglobin sets in a little 
later, but is eventually more marked than the fall in the 
red cell count; also, as improvement begins, the erythro- 
cytes increase more rapidly than does the haemoglobin. 



14 



THE SPLEEN AND ANEMIA 



The red cells seldom drop below 3,000,000 or the haemo- 
globin below 55 per cent. Not infrequently, when the 
blood picture has returned to normal, the figures are higher 



TABLE II 

HAEMOGLOBIN ESTIMATIONS AFTER SPLENECTOMY 



Prelimi- 


Dog 32 


Dog 33 


Dog 41 


Dog 44 


Dog 46 


Dog 57 


Dog 59 


nary esti- 
















mation 


lOOpercent. 


98 per cent. 


90 per cent. 


105percent. 


88 per cent. 


94 per cent. 


80 per cent. 


1* 


90 




70 


92 




105 


70 


3 


85 




70 


92 




95 


64 


5 


80 




70 


82 




83 


48 


7 


80 




70 


82 






55 


9 


80 




70 


72 




77 


65 


12 


75 




70 


72 


85 


62 


65 


15 


70 


88 


70 


62 


98 


70 




18 


65 




70 


60 


104 


77 


70 


21 


65 






58 




70 




24 


65 




60 




98 


71 


66 


27 






50 


55 


96 




63 


30 




80 


55 




95 


55 


74 


36 


70 






57 


68 


50 


70 


42 




52 


55 




75 


61 


80 


48 


70 


58 


55 


70 




76 


76 


54 


80 


78 


65 


72 




84 


74 


60 




82 








89 




66 


90 


78 


70 


75 




90 


78 


72 




70 








84 


75 


80 


90 


79 


90 


80 




82 




88 




78 








94 


72 


96 




66 




90 




97 


88 


104 


90 


62 


85 








94 


124 


95 


75 


80 


95 




90 




150 




94 


85 






110 


105 


240 


97 


100 


75 


68 




104 


105 


300 




102 


92 


81 




108 





* The figures in the first column refer to the number of days after splenectomy 

than before splenectomy. This is true of both the red 
cells and the haemoglobin. Lamson 2 * 5 has recently shown 
that strong emotions, such as rage or fear, by stimulating 
adrenalin secretion and thus changing the concentration 
of the blood constituents, can produce considerable changes 
in the red blood-cell count per cubic millimetre. In the 



EXPERIMENTAL STUDIES 



15 



animals whose blood counts are here reported, however, 
various observations indicate that such disturbing factors 
need not be considered. In the first place, the amount of 
emotion produced in the process of securing blood counts 
is slight, temporary, and often almost entirely absent. Fur- 
thermore, normal animals have been followed over consid- 
erable periods of time without appreciable change in their 
blood counts. 



Hemo- 
globin 


before 
Splenec- 


After Splenectomy Time in Dciys 


tomy 


i 


3 


5 


7 


9 


12 


15 


18 


z\ 


24 


27 


30 


36 


42 


46 


54 


60 


66 


72 


BO 


&b 


96 


104 


124 


I5O3MI500 




100% 




























































95 % 




















































rA 








90 I 


















































i 


<• 


\/ 


/ 




657 














































r— 




J 










80 1 






\ 






























/ 


A 




r 


V 
















157o 






\ 




























/ 






V 




















10% 


















A 




A 












/ 


























65% 




















V 




V- 




\ 


v 


J 




























60% 




















































































































— 





Fig. 2- — Composite curve of the haemoglobin estimation of seven dogs after splenectomy. 

The nature of the anaemia that follows splenectomy 
will be discussed later (see page 87), after some other 
factors which are dependent upon the removal of the spleen 
and have a possible relation to the anaemia have been pre- 
sented. Here it may be stated, however, that the stage 
of repair is not characterized by the constant appearance 
in the peripheral blood of nucleated or other abnormal 
types of red cells. Careful differential counts of the blood 
of three dogs at regular intervals for 138 days failed to 
reveal in two the presence of nucleated red cells, and in 
the other they were demonstrable only five times, the 
largest number seen in one count being three. In none of 



16 THE SPLEEN AND ANAEMIA 

these animals were other changes evident in the red cells, 
except the pale staining corresponding to a low haemoglo- 
bin content. In a large number of other animals in which 
differential counts were made at irregular intervals, changes 
in the red cells have been found very rarely. Thus in one 
dog, five weeks after splenectomy, five normoblasts and 
one megaloblast were found (in counting 100 leucocytes), 
as was also evidence of poikilocytosis and polychromato- 
philia, and, a week later, one normoblast and one megalo- 
blast. These findings were in the first days of beginning 
repair, the red cells and haemoglobin having a few days 
before reached the lowest level observed during the experi- 
nent; haemoglobin, 50 per cent.; red cells, 2,970,000. In 
another dog, two months after splenectomy, again at the 
stage of beginning repair (haemoglobin, 62; red cells, 
3,650,000), five nucleated red cells were found, and 
polychromatophilia was evident. In no instance did these 
findings persist for any length of time. They are of sig- 
nificance only in that they probably indicate the period of 
beginning repair. 

The very definite nuclear particles found by Morris, 300 
Roth, 385 and Gilbert 145 in the red cells of man after sple- 
nectomy we have not observed in the dog, despite repeated 
examinations made since Morris's second publication. This 
question of repair of the blood will be discussed again ( see 
page 140) in connection with the study of changes in the 
bone-marrow. 

The number of skeined or reticulated erythrocytes is 
very slightly, if at all, increased during the early stages 
following removal of the normal dog's spleen. Gates, 137 
on the other hand, has shown that there is an increase in 
the number of reticulated cells when the anaemia is greatest ; 



EXPERIMENTAL STUDIES 



17 



that is, just before the period of beginning repair. The 
blood-platelets also are only slightly increased after re- 
moval of the normal spleen. 

White Cells. — As our problem was one concerning 
the red rather than white cells, the latter have not been 
studied as thoroughly as have the red cells. We have, how- 
ever, total leucocyte counts of five dogs and differential 
counts of three dogs, in each instance covering long periods 
of time, 311 and on many others for shorter periods. The 
results of the total leucocyte counts are presented in Table 
III and Fig. 3, and of the differential counts in Table IV. 

TABLE III 
Leucocyte Count After Splenectomy 



Preliminary 


Dog 32 


D g4 1 


Dog 44 


Dog 57 


Dog 59 


count 


9,000 


12,000 


13,000 


14,400 


14,200 


1* 


26,000 


33,000 


36,000 


38,100 


28,700 


3 


26,000 


22,500 


21,500 


21,100 


13,800 


5 


28,000 


21,000 


13,000 


17,000 


11,400 


7 


25,500 


23,000 


13,000 




17,900 


9 


28,000 


19,000 


14,000 


22,000 


14,400 


12 


22,000 


21,000 


13,000 


19,200 


17,800 


15 


25,000 


18,000 


16,000 


19,600 




18 


19,000 


19,000 


18,100 


18,700 


16,800 


21 


18,000 


14,000 


16,400 


18,400 




24 


15,000 






18,600 


12,100 


27 




15,000 


12,000 




11,800 


30 


33,000 


15,000 


14,200 


16,000 


13,400 


36 








16,900 


15,300 


42 


16,000 


11,000 


11,200 


19,000 


12,100 


48 




12,000 




19,200 


17,400 


54 


11,000 


11,000 


10,000 


15,000 


13,100 


60 








16,100 




66 


13,000 






17,600 


11,600 


72 




12,000 


11,200 


16,400 


12,200 


80 


14,000 


12,000 




16,000 




88 






9,900 


18,100 


13,600 


96 
304 
i24 


13,000 


13,000 


11,000 


20,100 


9,000 


15,000 


13,000 


12,400 


16,000 




240 








16,400 


15,000 



* The figures in this column refer to the number of days after 
splenectomy. 



18 



THE SPLEEN AND ANAEMIA 



The leucocyte picture was quite constant. On the day 
after splenectomy the white cells rose from a normal level 
of 9000-14,000 to 38,000 per cubic millimetre, or even 
higher, and in a few days fell rapidly to about 20,000, after 
which there was a more gradual decrease with return to 
approximately the normal level after a period ranging from 
one to four months. The initial leucocytosis was due 
mainly to an increase in the polymorphonuclear neutro- 
philic leucocytes, and was probably a post-operative effect 



Leuco- 
cytes 


Before 
Splenec- 


After Splenectomy Time in Days 


t 


f omy 


i 


3 


5 


7 


9 


12 


15 


18 


21 


27 


36 


42 


48 


54 


66 


80 


96 


24 


\m 




















34,000 




4 
























































. 32.000 




B 
























































30.000 




P 






















































aaooo 




L 






















































26000 


/ 


























































24.000 


/ 


























































£2.ooo 


/ 


























































20,000 


/ 








r- 


-Y 
















































jaooo 


/ 






V 


/ 




V 


^ 


7\ 










































16000 


/ 
















\ 










































14000 


/ 






































w 




















12000 


< 




































s^ 























Fig. 3. — Composite curve of the leucocyte counts of five dogs after splenectomy. 

and not due to the specific absence of the spleen. Lympho- 
cytosis, although usually described, has been found only 
to a slight degree in this series. At no time were the 
lymphocytes recorded as higher than 34 per cent., while 
the average count in all dogs was about 18 to 26 per cent. 
In the parallel observations on the results of diverting the 
splenic blood from the liver without removal of the spleen, 
the early polymorphonuclear leucocytosis and later lym- 
phocytosis were also noted. The behavior of the eosino- 
phils has varied; in two dogs (not presented in Table IV) 
an eosinophilia of 10 to 32 per cent, persisted for 113 
days in one, and in the other an eosinophilia of 6 to 11 



EXPERIMENTAL STUDIES 



19 



TABLE IV 
Differential Counts of White Cells After Splenectomy 

Dogl 



Time 


Leucocytes 


Polynucleara 


t 

Lympho- 
cytes 


t 

Eosinophilcs 


t 

Other 
forms 


Before operation 


12,500 


8,625 


3,000 


500 


375 


*1 


45,200 


37,100 


5,880 


450 


1,770 


3 


22,400 


17,250 


3,360 


560 


1,230 


7 


25,600 


18,700 


4,340 


1,280 


1,280 


13 


25,100 


19,500 


4,100 


1,000 


500 


21 


18,600 


13,580 


4,460 


370 


190 


33 


17,100 


11,950 


4,360 





790 


47 


14,500 


10,140 


4,000 





360 


68 


13,600 


9,590 


3,460 





550 


82 


14,700 


11,250 


2,860 


150 


440 


96 


13,100 


9,560 


2,360 


785 


395 


111 


12,700 


8,000 


3,230 


700 


770 


138 


15,900 


9,700 


2,380 


2,070 


1750 



Dog 2 



Before operation 


10,100 


7,770 


1,615 


200 


515 


*1 


48,400 


43,570 


2,905 


240 


1685 


3 


25,100 


19,300 


3,890 


1,510 


400 


7 


23,100 


17,750 


4,430 


230 


690 


13 


18,200 


13,650 


3,640 


90 


820 


21 


16,800 


12,600 


3,700 





500 


33 


15,100 


11,180 


3,470 





450 


47 


12,600 


9,350 


2,750 





500 


68 


11,400 


8,780 


2,280 





340 


82 


12,600 


9,340 


2,700 





560 


96 


11,900 


8,360 


2,610 


360 


570 


111 


11,800 


8,550 


1,770 


760 


720 


138 


16,100 


11,110 


1,770 


1,610 


1,610 



Dog 8 



Before operation 


12,500 


8,650 


3,380 


190 


280 


*1 


26,900 


21,480 


3,500 


1,070 


850 


3 


21,100 


15,750 


4,720 


210 


420 


7 


12,200 


8,800 


2,650 


250 


500 


13 


16,100 


11,350 


4,520 





230 


21 


14,100 


9,850 


3,590 





660 


33 


14,100 


10,860 


2,820 





420 


47 


12,100 


8,660 


3,200 





240 


68 


12,000 


8,400 


3,360 





240 


82 


10,300 


7,420 


2,680 





200 


96 


13,100 


8,540 


3,530 


450 


580 


111 


13,700 


9,040 


3,560 


410 


690 


138 


13,800 


9,660 


1,930 


410 


1,800 



* Numbers in the first column indicate the number of days after operation; numbers in 
the other columns indicate the number of cells per cubic millimeter, 
t Calculated on basis of 200 cells counted. 



20 THE SPLEEN AND ANAEMIA 

per cent, for 107 days. On the other hand, in three dogs 
the eosinophiles disappeared entirely for long periods of 
time, corresponding roughly to the third to eleventh week,* 
but this disappearance was followed later by an increase 
varying from 6 to 20 per cent, of the total white cell count. 
This disappearance, as may be seen in Table IV, corre- 
sponded to the point of severest anaemia (thirty-third, 
twenty-first, and thirteenth days), and the reappearance 
to the period when the blood has returned, or nearly so, to 
its normal level (eighty-second, ninety-sixth, ninety-sixth 
day) . As to its significance we have no opinion. 

In all differential counts especial search has been 
made for unusual cells, as myelocytes. These have seldom 
been found. In the counts shown in Table IV, represent- 
ing three different dogs, basophilic myelocytes were found 
only four times, and no other atypical leucocytes were seen. 
In a fourth animal, two months after splenectomy, baso- 
philic myelocytes (5 to 100 cells) were found once at the 
period of beginning repair. 

The literature of experimental splenectomy, while it 
presents rather widely varying results, is, on the whole, in 
accord with our experience. Dissimilar results are re- 
ported by Paton, Gulland, and Fowler, 330 who state that in 
the dog, cat, and rabbit the removal of the spleen has no 
influence on the red corpuscles. An examination of their 
tables shows, however, that in the dog they did obtain a 
slight anaemia, a decrease of 600,000 to 800,000 red cells, 
which, however, occurred also in one instance in a normal 
dog. Moreover, they used puppies about two and a half 

* In one of our papers 311 in which we refer to this phenomenon, the 
period is given as " the third to the eleventh day." This is incorrect 
and should read " week " instead of " day." 



EXPERIMENTAL STUDIES 21 

months old, and it is possible that in such young animals 
the mechanism of blood destruction and regeneration may 
not be the same as in older dogs. Our observations were 
mostly upon full-grown dogs, but in the few puppies 
studied the results were substantially the same. Other 
results not in accord with ours are those of Azzurrini and 
Massart, 24 who made frequent counts on four dogs over 
periods of 15 to 18 months after splenectomy. In none 
was a drop of more than 5 per cent, haemoglobin or 100,000 
red blood corpuscles noted. In this connection we may 
point out that where anaemia fails to develop, the possi- 
bility of accessory spleens which are sometimes found in 
the dog must be considered. Zanda, 484 for instance, failed 
to find the usual changes after splenectomy, and states 
that this was due to the presence of accessory spleens. 
Diet, as we will show later, also has an important influence 
on the degree of anaemia. Wolferfh 47T has recently shown 
that the same changes occur in the blood of Albino rats 
after splenectomy that we have found in dogs. In eight 
rats which had abnormally large spleens, splenectomy was 
followed by rapid severe anaemia, hyperleukocytosis, 
marked increase in the number of nucleated and reticulated 
cells, and proved fatal in seven of the eight. 

Picard and Malassez, 352 by the crude methods of early 
blood examination, found a diminution in both red cells 
and haemoglobin, but considered the latter to be more 
definite. Vulpius, 460 Gibson, 140 Laudenbach, 240 Grigo- 
rescu, 155 Winogradow, 475 and Tauber 425 record a decrease 
in red cells after splenectomy in the dog, and Vulpius 
describes a leukocytosis, as does also Gibson. The degree 
of anaemia, as well as its severity and the time of repair 
as observed bv these different investigators, varies widelv, 



22 THE SPLEEN AND ANEMIA 

but they are in general accord as to both anaemia and leuco- 
cytosis. That anaemia occurs in other animals than the dog 
is shown by Warthin's 461 observations on the sheep and 
goat. On the other hand, the changes in the rabbit and 
guinea-pig are not so uniform. Gabbi 135 found in guinea- 
pigs an increase in red cells and haemoglobin, and in the 
rabbit no change or a slight decrease, as did also Zezas. 485 
In the rabbit and cat, Paton, Gulland, and Fowler 33 ° 
found no changes. Asher and Sollberger 17 have recently 
stated that in the rabbit removal of the spleen causes an 
increase of both red cells and haemoglobin, and that this 
increase is due to the removal of the normal haemolytic 
activity of the spleen and to stimulation of the bone-mar- 
row. Their observations, however, were made only a short 
period after splenectomy, so that the rise noted may be 
similar to that occasionally found by us in dogs immedi- 
ately after splenectomy. Most of the observations con- 
cerning the anaemia following splenectomy are, in fact, 
incidental to other problems or are based on occasional 
examinations, which perhaps accounts for some of the 
discrepancies. We feel, however, that in the large num- 
ber of animals which we have studied it is conclusively 
shown that a secondary anaemia of some degree is, in the 
dog at least, a characteristic result of splenectomy. The 
variations in the degree of anaemia are, however, so marked 
that we have made a prolonged study of the influence of 
diet 337 in the hope of explaining these variations. 

Influence of Diet on the Ancemia. — In these studies 
we had in mind: (1) the observations of Asher and 
Vogel, 18 that while an iron-poor diet (sugar, starch and 
lard ) has no effect upon the blood picture in a normal dog, 
in the splenectomized dog on the same diet, a great decrease 



EXPERIMENTAL STUDIES 23 

in number of red cells and amount of haemoglobin occurs ; 
and further, if under the latter circumstances an iron-rich 
(flesh) diet is given, the blood picture quickly returns to 
normal; (2) Richet's 3T4 observation that in order to main- 
tain splenectomized dogs at the same weight as normal 
dogs, a much larger quantity of food is necessary, and ( 3 ) 
Paton's 329 conclusion opposed to that of Richet, that 
splenectomy in the dog has no influence upon general 
metabolism. 

In regard to Asher and Vogel's contention, we have not 
found by a direct quantitative study (see page 112) of 
the elimination of iron that splenectomy seriously influ- 
ences iron metabolism. 22 Moreover, in our opinion, the 
time of improvement in the anaemia which these investi- 
gators describe as the result of feeding iron-rich food 
corresponds to the spontaneous repair of the anaemia which 
usually begins about the end of the fourth week. In 
other words, the improvement was, in our opinion, due 
in part at least to the normal repair and not to the effect 
of the iron-rich food. Their conclusions would be more 
convincing if they had prevented entirely, or lessened, the 
severity of the anaemia by beginning the feeding imme- 
diately after splenectomy instead of waiting nearly three 
weeks. As to Richet's point, it may be noted that we have 
not seen noteworthy changes in the weight of our splenecto- 
mized animals. For a few days after splenectomy, a slight 
loss may occur, but in all long time experiments an in- 
crease beyond the original weight has been observed. 

The studies of Paton and his associates as to the changes 
in the blood after splenectomy are the most carefully 
conducted of any in the literature and for this reason we 
have been greatly disturbed that our results were so differ- 



24 THE SPLEEN AND ANAEMIA 

ent. Their studies, however, were limited to two splenecto- 
mized animals and two controls and it may be that by 
chance the former correspond to the milder anaemias which 
we observed. In their studies of the blood 33 ° diet is not 
mentioned, but in the metabolism 329 work the dogs were 
for part of the time at least on a meat (high iron) diet, 
which, if used in the blood work also, might have been, if 
Asher and Vogel are correct, a factor in decreasing the 
ansemia. It is evident from this brief review that diet may 
be an important factor in determining the degree of ansemia 
following splenectomy. 

Until our special investigations of the influence of diet 
were undertaken, all animals, except those used in the 
study of iron metabolism, 22 had been kept upon the same 
general diet — a mixture of meat, bread, cereals and vege- 
tables — in all essentials, the " table scraps " upon which 
dogs are usually fed. This was always supplied in abund- 
ance and each dog received all he would eat, and as our 
records show that the splenectomized dogs during periods 
of several months gained in weight on this diet, we con- 
sidered it highly satisfactory. However, we did not know 
the exact caloric value of this mixed diet and, moreover, 
as it was essentially a boiled diet, it might possibly be 
deficient in some substance essential to the proper function 
of the hemopoietic system. Therefore, in our first group 
of dietary experiments animals were placed on calorically 
sufficient diets, the protein being furnished in the form of 
beef heart, beef spleen, or commercial casein, and the fat 
and carbohydrate in the form of lard and bread crumbs. 
Beef spleen was introduced on account of its large iron 
content in contrast with that of the beef heart and the 
casein. Several blood examinations were made during a 



EXPERIMENTAL STUDIES 



2.5 



period of ten days to two weeks before splenectomy and 
at intervals, never exceeding a week, after operation. In 
Tables V, VI, and VII, which show the results of these 
studies, only the last two blood counts of the preliminary 
periods are given. These represent, usually, counts made 
respectively 1 to 2 and 5 to 7 days before splenectomy. 
As the blood of the several dogs was not always exam- 
ined at exactly the same intervals after splenectomy, in 

TABLE V 
Influence of Diet 



Days 



Raw beef heart, lard, and bread 



Dog 79 (splenectomized) 



Weight 



ed cell 
count 



Haemo- 
globin 



Dog 83 (splenectomized) 



Weight RfdceU 



Haemo- 
globin 



Before splenectomy 



kilos. 
9.3 



7,930,000 
7,560,000 



percent. 
110 
114 



kilos. 
8.7 



7,000,000 
7,770,000 



percent 
107 
105 



After splenectomy 



5- 7 
10-14 
18-23 
26-33 
38-40 
45-48 
52-61 



8.8 


7,420,000 


97 


8.6 


7,910,000 




7,230,000 


98 




7,720,000 




6,250,000 


98 


8.6 


6,500,000 




6,810,000 


96 


8.7 


7,270,000 


9.8 


7,360,000 


104 


8.3 


6,880,000 


10.5 


6,690,000 


100 


8.5 


6,260,000 


10.8 


6,640,000 


95 


8.6 


6,240,000 



105 
103 



101 
97 



93 



Days 



1 

4- 7 

12-18 

26-40 

40-60 



Raw beef heart, lard, and 
bread 



Dog 81 (control) 



Weight 



kilos. 
9.1 



10.0 
10.1 



Red cell Haemo- 
count globin 



6,320,000 
6,650,000 
6,880,000 
6,800,000 
6,000,000 



percent. 
97 
102 
96 
90 
96 



order to shorten the table, only enough blood counts are 
given to show the general trend of the blood picture. The 
figures for iron and of nitrogen in the diet are based on 
the average of several estimations of the food materials 
used. These figures with a calculation of the caloric value 
of the food are given in Table VIII. 

By comparing Tables V, VI and VII it is at once 
evident that in no instance did the general nutrition of the 
animals suffer. A slight loss of weight occurred after 
operation, but this was soon regained. Also it is seen that 



26 



THE SPLEEN AND ANAEMIA 



in no instance does a splenectomized dog maintain the same 
constant level of red cell and haemoglobin content as do the 
non-splenectomized animals. The change, however, in 
Dogs 79, 83, 84 and 87 is so slight as to be within the limit 
of error of the methods of blood examination; in 82, 85 
and 86 the change is more marked, but even here one can 
hardly refer to the condition present as a frank ansemia. 
It is, however, of significance that in all instances the varia- 

TABLE VI 
Influence op Diet 





Casein, lard, and bread 


Days 


Casein, lard, and bread 


Days 


Dog 82 (splenectomized) 


Dog 84 (splenectomized) 


Dog 80 (control) 




Weight 


Red cell 

count 


Haemo- 
globin 


Weight 


Red cell 
count 


Haemo- 
globin 


Weight 


Red cell 
count 


Haemo- 
globin 


Before splenectomy 


1 

4- 7 
12-18 
26-40 
40-60 


kiloa. 
9.1 

8.3 
9.2 


7,860,000 
7,420,000 
7,020,000 
7,370,000 
7,180,000 


percent. 




kilos. 
16.7 


5,500,000 
5,551,000 


percent. 
98 
85 


kiloa. 
8.7 


7,780,000 
7,710,000 


percent. 
98 
97 


90 
92 
96 
96 
103 


After splenectomy 


5- 7 
10-14 
18-23 
26-33 
38-40 
45-48 
52-61 


16.5 
17.2 

16.9 


4,600,000 
4,688,000 
4,210,000 
5,160,000 
6,040,000 

6,060,000 


75 
65 

76 
82 

88 

90 


8.6 
8.8 
8.9 
9.1 
9.2 

9.1 


7,090,000 
7,140,000 
6,600,000 
7,010,000 
6,940,000 
6,630,000 


89 
92 

91 
92 
87 
91 





tions are more marked than in the controls and also that 
they usually occur after about four weeks, the period, in 
post-splenectomy ansemia, usually marked by the lowest 
counts. On the other hand, the question arises, are these 
results in some way due to the diet, that is, to the general 
character of the diet, or to the presence of large amounts 
of iron? That iron in the diet is a factor seems doubtful 
in view of the fact that two of the three animals (85 and 
86) , fed with beef spleen, showed the most marked changes 
of any in the group. Beef spleen was selected because it 



EXPERIMENTAL STUDIES 



27 



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28 



THE SPLEEN AND ANAEMIA 



contains a large amount of iron, according to our analyses 
235 mg. per 100 grams, presumably in large part in organic 
combination and therefore readily utilizable. Fresh beef 
heart and casein, on the other hand, contain only 4.6 mg. 
and 7.2 mg. per 100 grams respectively, and if iron is an 
important factor in preventing anaemia after splenectomy, 

TABLE VIII 

Nitrogen and Iron Content and Caloric Value of Diets of Tables 

V, VI, VII 





Actual total per day 


Per kilo of body weight 


per day 


Dog No 










Nitrogen 


Iron 


Calories 


Nitrogen 


Iron 


Calories 




gm. 


mg. 




gm. 


mg. 




79 


6.5 


11.8 


709 


0.72 


1.31 


79 


83 


9.8 


18.0 


1,043 


1.17 


2.15 


124 


81 


6.5 


11.8 


665 


0.68 


1.23 


69 


82 


13.6 


11.3 


1,194 


0.81 


0.68 


71 


84 


10.6 


9.1 


956 


1.18 


1.01 


106 


80 


7.4 


6.2 


664 


0.82 


0.69 


74 


85 


4.6 


352.0 


517 


0.69 


53.00 


77 


86 


8.3 


653.4 


893 


0.69 


54.00 


74 


87 


6.8 


543.0 


752 


0.68 


54.00 


75 


90 


4.6 


352.0 


517 


0.64 


49.00 


72 



one would not expect animals fed with spleen to show the 
changes evident in the figures given for Dogs 85 and 86; 
rather, one would expect figures as in experiment 87. The 
changes in these three animals, in all probability, represent 
the variation to be expected in any group of animals. That 
the administration of abundant organic iron in the form 
of beef spleen, did not prevent the anaemia, is in accord 
with our studies 22 of iron metabolism* in the absence of 
the spleen and opposed to the conclusion of Asher and 
Vogel. 18 

On the other hand, in view of the slight changes which 

* See page 112. 



EXPERIMENTAL STUDIES 29 

occurred in some of the animals, it is impossible to avoid 
the question as to whether a diet adequate for the normal 
dog is in some way inadequate for the splenectomized dog. 
If the latter could be demonstrated the value of our views 
concerning the severer types of anaemia following sple- 
nectomy, based on our earlier experiments upon dogs fed 
on a general mixed diet, would depend upon whether or not 
the inadequacy of diet held for all animals operated upon, 
or only for animals without a spleen. If anaemia occurred in 
dogs fed on the mixed diet after other operations than sple- 
nectomy, it would be at once evident that the food, while 
sufficient for a normal dog, was not sufficient for a con- 
valescent dog. On the other hand, if the anaemia could 
be demonstrated only after splenectomy, there would be 
established a point of importance in regard to the spleen 
in its relation to metabolism, and our observations on the 
anaemia after splenectomy would not only be substantiated, 
but would gain an added importance. To settle this point, 
it was essential, therefore, to study in animals on our rou- 
tine mixed diet the effect of splenectomy, and as a control 
some other simple operation involving the removal of an 
organ. Nephrectomy was selected as an operation quite 
analogous, from the technical point of view, to splenectomy, 
and accordingly two healthy dogs were placed upon ordi- 
nary kennel diet for seventeen days; upon each dog a 
nephrectomy was then performed and the animals kept on 
the same diet for twenty-three days longer; splenectomy 
was then performed upon each dog and the animal kept 
on the same diet for thirty-eight days more. Blood counts 
were made at frequent intervals throughout the experi- 
ment. Whereas during the seventeen days on the diet 
before operation and during the twenty-three days follow- 



30 



THE SPLEEN AND ANEMIA 



ing nephrectomy no significant change (see Table IX) 
in the haemoglobin or red blood-cells was observed in either 
animal, after the splenectomy both showed a well-marked 
fall in haemoglobin and red blood-cells count. It is note- 
worthy, also, that relatively slight change in weight 
occurred. 



TABLE IX 

Effect of Splenectomy Controlled by Previous 

Diet 



Nephrectomy. Mixed 





Dog 23 


Dog 42 


Date 


Weight 


Haemo- 
globin 


Red blood 
count 


Weight 


Hemo- 
globin 


Red blood 
count 


May 18 ... . 

May 25 

June 1 . . . . 


kilos. 

10.9 
10.9 
11.0 


per cent. 

100 
98 
92 


6,840,000 
7,240,000 
6,760,000 


kilos. 

14.1 
14.0 
14.9 


per cent. 

102 
102 
101 


7,810,000 
7,850,000 
8,330,000 


June 4 . . . . 


Nephrectomy 


Nephrectomy 


June 8 . . . . 
June 15 ... . 
June 25 ... . 


11.1 
11.3 
11.4 


93 
90 
97 


6,280,000 
6,020,000 
6,690,000 


14.0 
14.6 
14.8 


98 
95 

97 


7,210,000 
7,120,000 
7,010,000 


June 27 


Splenectomy 


Splenectomy 


July 3 . . . . 
July 10.... 
July 18.... 
July 27.... 
Aug. 4 . . . . 


10.9 
10.8 
10.8 
10.4 
10.4 


90 
83 

77 
66 
68 


6,600,000 
5,890.000 
5,740^00 
5,080,000 
4.540,000 


15.1 
14.9 
14.9 
14.3 
14.2 


90 
92 
88 
75 
76 


6,840,000 
6,830,000 
6,480,000 
6,060,000 
6,350,000 



From these observations four conclusions may be 
drawn : ( 1 ) that, inasmuch as the animals maintained their 
average weight, the routine " table scrap " diet is a satis- 
factory food for animals after surgical operations; (2) 
that on this diet, operation involving the removal of an 
organ other than the spleen does not cause anaemia; (3) 
that the anaemia following splenectomy is not to be ex- 
plained, in view of the fact that the splenectomized animals 
maintained their average weight, by insufficient nutrition; 



EXPERIMENTAL STUDIES 



31 



and (4) if the anaemia is in any way related to the diet, it 
is either (a) because some toxic substance, which operates 
in the absence of the spleen, is present in this particular 
food, or (b) because some substance present in the diet and 
normally utilizable cannot be utilized in the absence of 
the spleen. In connection with this last conclusion, it 
occurred to us that, as the routine kennel diet is essentially 
a cooked diet, it was possible that in the cooking there 
occurred the destruction by heat of some vitamin-like sub- 
stance normally utilized by the spleen. To control this 

TABLE X 

The Influence Upon the Anaemia Following Splenectomy of a Raw and a 

Cooked Diet 











Food 










values per 






Before splenectomy 


After splenectomy 


kilo, of 

body 

weight 










Dog 


Diet 








No. 




c 
o 


6 = 

S3 
8 o 


v a 


T3 

.2 

o 

Ph 


"5"t£ 




"3 -t> 

o a 

"88 


13 
© 

o 

(-. 

2 


■ 

o 

•a 

O 










per 








per 












days 


kilos. 


cent. 




weeks 


kilos. 


cent. 




gtn. 




48 


Raw 


28 


13.4 


99 5,450,000 


6th- 9th 


14.0 


96 


5,590,000 


0.41 


69 


57 


u 


25 


10.9 


100 ; 6,220,000 


6th-12th 


12.4 


83 


4,499,000 


0.46 


75 


53 


a 


24 


8.0 


99 .6,140,000 


8th-12th 


8.9 


75 


4,920,000 


0.74 


69 


52 


(C 


41 


8.5 


104 6,910,000 


10th-13th 


8.6 


83 


5,551,000 


0.15 


72 


52 


Cooked 


48 


10.8 


105 1 6,760,000 


7th- 9th 


11.4 


77 


5,130,000 


0.40 


69 


56* 


tt 


121 


8.4 


88 ( 6,250,000 


6th-10th 


7.8 


61 


4,880,000 


0.40 


73 



Controls 



9 



56 : 



Raw 



Cooked 



108 



121 



11.4 

12.9 

8.2 

8.4 



102 
95 

100 
88 



6,620,000 

(initial 
period) 

6,590,000 
(final 
period) 

6,460,000 
(initial 
period) 

6,250,000 
(final 
period) 



* This animal was used first as a control for the cooked diet and later was splenectomized. 



32 THE SPLEEN AND ANAEMIA 

point (see Table X) a new series of observations were 
undertaken. Six animals were placed upon a calorically 
sufficient diet, accurately determined, the only difference 
being that four received raw and two cooked meat. Exam- 
inations of the blood were made at intervals of not longer 
than seven days. At the same time metabolism studies, 
the results of which are described elsewhere,* were made 
on some (No. 48, 57, 52, and 56) of the animals. The 
diet in each of these experiments consisted of beef -heart, 
lard, and sugar, a small amount of sodium chloride, and 
sufficient bone-ash to ensure firm faeces. Details of nitro- 
gen content and caloric value of the foods are given in 
Table X. In connection with this table, it should be ex- 
plained that, in order to place the figures covering all 
animals in one graphic table, the counts given represent 
averages of several examinations. The 'figures before 
splenectomy represent the averages of the last three counts 
before operation; the figures after splenectomy, the aver- 
age of the three lowest consecutive counts. The figures for 
the two control animals represent the average of the first 
three and last three counts respectively. 

It is evident, from a study of this table, that there is a 
greater tendency for animals on the cooked diet to develop 
anaemia than is the case with those receiving raw meat. 
Thus in the latter group no change in the blood picture 
was evident in one animal, while in the other three with 
moderate ansemia the haemoglobin did not fall below 75 
or the red cells much below 5,000,000. On the other hand, 
both animals receiving cooked meat showed a marked 
change in the blood picture, and in one a haemoglobin con- 
tent as low as 61. The haemoglobin decrease is relatively 

* See page 181. 



EXPERIMENTAL STUDIES 33 

greater, as in all our previous studies, than is the fall in 
red cells. That the amount of protein given in the raw 
food is not an important matter is seen by contrasting 
Dog 53 on a high nitrogen diet with Dog 50 on a low 
nitrogen diet. In these two animals the calories of the 
diet were maintained by varying the amount of fat. The 
difference in the degree of anaemia is negligible. In con- 
nection with the problem of the influence of cooked diet, 
it is noteworthy that Dog 56, which served as a control 
to 52 for four months before it was splenectomized, and 
was living all this time on a cooked diet, showed during 
this time a falling off in the haemoglobin content of its blood. 
Moreover, this animal was the only one showing a per- 
sistent loss of weight after splenectomy. Definite con- 
clusions cannot be drawn from such a small number of 
experiments, but the fact that splenectomized animals on 
cooked beef develop an anaemia of a degree more closely 
approaching that of animals on the usual kennel diet, 
essentially a cooked diet, while animals on a raw diet have 
a less severe anaemia, suggests that heat brings about some 
change in the diet, which in the absence of the spleen is a 
factor in causing anaemia. In view, however, of the rela- 
tively slight differences which we have found, experiments 
on a large number of animals on diverse diets must be made 
before a final decision can be reached on this point. Our 
views at present may be summarized as follows: 

1. The anaemia which develops after splenectomy is 
most marked in animals on a mixed " table scrap " diet of 
meat, bread, cereals, and vegetables, which is essentially a 
cooked diet. 

2. Control studies in which a unilateral nephrectomy 
precedes splenectomy demonstrates that the anaemia is 

3 



34 THE SPLEEN AND ANAEMIA 

not due to operation, hemorrhage, or accidents of conva- 
lescence, but develops only in the absence of the spleen. 

3. The results of studies of the influence of food con- 
taining a large amount of iron in presumably easily utiliza- 
ble form, as in raw beef spleen, does not support the view 
that the anaemia is due to lack of iron in the food. 

4. Observations on the influence of a diet of raw meat 
as contrasted with cooked meat show a more severe anaemia 
in animals on the cooked diet, and suggest the possibility 
that heat alters some substance which the body cannot 
utilize in the absence of the spleen. 

Blood Changes in Man After Splenectomy 

Concerning the influence of splenectomy in man, a 
wide difference of opinion exists. This is reflected in the 
text-books on haematology; for example, DaCosta recog- 
nizes a diminution of red cells and haemoglobin and a leuco- 
cytosis, the former continuing one to three months, the 
latter four to six weeks. Cabot does not mention changes 
in the red cells or haemoglobin. Grawitz says there is no 
especial change in the red cells. All these authors, how- 
ever, recognize a lymphocytosis and an eosinophilia. 

It is not difficult to understand this difference of 
opinion. The spleen is usually removed for some acute 
traumatic condition, as rupture, or some chronic sple- 
nomegaly associated with anaemia, in all of which conditions 
the blood picture is altered. Frequently, also, no pre- 
liminary blood examination is made, and if such examina- 
tion is made, observations are not continued long after 
operation. Under these conditions it is not surprising that 
opinions should vary. Accurate information concerning the 
influence of the spleen must be based on extirpation, for 



EXPERIMENTAL STUDIES 35 

some localized lesion which replaces or affects only a small 
amount of the organ, does not alter the function of the 
remainder, and has in itself no influence on the blood pic- 
ture. When the spleen is removed under such conditions, 
as in a simple cyst, or for misplacement, or for injury 
without massive hemorrhage, the blood picture being nor- 
mal before operation, definite conclusions concerning the 
effect of splenectomy may be reached. A few instances 
of this kind exist in the literature. For instance. Darling, 88 
before the removal of a simple non-parasitic cyst of the 
spleen, found the haemoglobin to be 90 per cent, and the red 
blood-cell count on two occasions 4.290,000 and 4,750,000, 
respectively. The day after a relatively simple operation, 
without hemorrhage, the red blood-cell count had dropped 
to 3,937,000, and three days after operation to 3.280,000. 
Three weeks later the haemoglobin had returned to 100 
per cent, and the red blood-cells to 4,700,000. Dr. Darling 
has been good enough to write us that three years after 
operation the blood examination was as follows : Haemo- 
globin. 100 per cent.; red blood-cells, 5,300.000; and leuco- 
cytes, 10,000, of which polymorphonuclears form 75 per 
cent., small lymphocytes 12 per cent., large mononuclears 
5 per cent., and eosinophiles 8 per cent. 

Catellani, 67 in a preliminary count before extirpation of 
a movable spleen, found haemoglobin 70 per cent, and red 
blood-cells, 4,435.500. One month after operation the 
haemoglobin had dropped to 60 per cent, and the red blood- 
cells to 3.500,000. After ten weeks the haemoglobin had 
returned to 75 per cent, and the red blood-cells to 6,050,- 
000; white cells. 28.310. Meyers 287 reports a child of 
eleven years splenectomized three days after an injury 
causing rupture of the spleen. On the evening of operation 



36 THE SPLEEN AND ANAEMIA 

the blood picture was: Red cells, 5,250,000; white cells, 
28,000. Within twenty-four hours the red cells fell to 
3,030,000, and at the end of twelve days to 2,980,000. The 
haemoglobin figures (Tallqvist) offer little of value : Great 
variations in the red cell count were observed for three 
months with gradual improvement, but not complete return 
to normal in that time. 

McCoy 26 ° reports two cases of rupture, one of a nor- 
mal, the second of a malarial spleen. In the first, on which 
seven counts were made, the haemoglobin fell from 70 per 
cent, before operation to 20 per cent, three days after 
operation and steadily rose to over 100 per cent, sixteen 
months after operation. The red blood-cells numbered 
3,408,000 before operation, fell to 2,300,000, and steadily 
rose to 5,560,000. The patient with malarial spleen showed 
haemoglobin 70 per cent., red blood cells 4,000,000 before 
operation, with a fall to 35 per cent, and 2,496,000 imme- 
diately after the operation, and a rise to 90 per cent, and 
5,456,000 seven months later. 

In the case reported by Matthew and Miles 27S a count 
made three days after splenectomy for rupture showed 
3,800,000 red blood-cells and 80 per cent, haemoglobin, and 
after two years, 4^800,000 red blood-cells and 85 per cent, 
haemoglobin. 

Heaton m reports a splenectomy for traumatic rupture 
in a child nine years of age. The operation was done five 
and one-half hours after the injury, when serious symp- 
toms of internal hemorrhage had developed. No prelimin- 
ary or early counts were made — a count seven days after 
operation showed 4,100,000 red cells and haemoglobin 40 
per cent. ; after five months of otherwise perfect recovery 
the blood picture was 4,480,000, haemoglobin 75 per cent. 
The usual leucocytosis was observed. 



EXPERIMENTAL STUDIES 



37 



Fowler, 120 a few hours after splenectomy for movable 
spleen, found the red cells to number 3,900,000 and the 
leucocytes 34,200. Daily counts thereafter for twenty- 
seven days showed a gradual decrease in the red cells, with 
a slight increase at the end of that time to 4,147,000, the 
white cells at the same time being 12,880. Unfortunately, 
no blood examination w r as made before operation. 

Musser's 310 case of cyst of the spleen illustrates well the 
degree of anaemia which may occur and the long duration 



TABLE XI 

Blood Examinations Before and After Removal of the Spleen for 

Simple Cyst 















Mono- 








Haemo- 
globin 


Red blood 
cells 


Leuco- 
cytes 


Polymor- 
phonu- 
clears 


Lym- 
pho- 
cytes 


nuclears 

and 
transi- 
tionals 


Eosin- 
ophiles 


Baso- 
phils 


Before operation 


70 


4,360,000 


11,400 


7,410 


3,310 


340 


340 





8 days after .... 


90 


4,642,000 


11,400 


8,050 


1,660 


1,390 


270 


30 


18 days after .... 


87 


3,916,000 


13,900 


8,340 


3,340 


2,220 








9 months after . . 


80 


4,400,000 


17,000 


11,950 


4,250 


700 


100 





15 months after. . 


75 


4,220,000 


14,800 














22 months after. . 


75 


2,750,000 


12,600 










. . . 




25 months after. . 


80 


3,460,000 


13,200 









, . . 




28 months after. . 


78 


3,400,000 


14,800 









. . . 




40 months after. . 


80 


3,590,000 


17,200 


9,370 


7,3i6 520 





6 



of the same. The patient was a young woman, twenty-five 
years of age, with, for seven years, a swelling in the left 
side of the abdomen. At operation was found a large 
benign cyst of the spleen measuring 18 cm. in diameter. 
The spleen with cyst wall (after evacuation) weighed 400 
grammes, so that, exclusive of the cyst, the spleen itself 
was not greatly enlarged. In the detailed statement of 
the blood examinations, presented in Table XI, it will be 
seen that a slight anaemia existed before operation. 

Staehelin 413(a) has collected from the literature up to 
1903 twenty-one cases of splenectomy following injury 



38 THE SPLEEN AND ANAEMIA 

and constituting, therefore, removal of the normal spleen. 
In very few of these cases was preliminary examination of 
the blood made, and in only three instances was the blood 
examined more than three times, and usually at very ir- 
regular intervals. In all cases there is evidence of some 
grade of anaemia after operation, but the counts were not 
sufficiently numerous to allow of definite opinion as to the 
general course of the anaemia. The figures as to leuco- 
cytosis vary greatly. 

These few records presented in detail have been selected 
from a large number of reports, most of which, because 
they present no preliminary counts or only occasional 
counts, are of little value in furnishing reliable evidence 
of the influence of splenectomy on the blood picture. Such 
evidence as we have shows very distinctly that in man both 
red cells and haemoglobin decrease, the latter more than the 
former, after splenectomy. Some confusion exists because 
of the improvement in the blood picture that follows opera- 
tion for removal of the enlarged spleen of the various types 
of " splenic anaemia." In these cases, however, an abnor- 
mal spleen is removed under abnormal conditions of the 
blood, and not a normal spleen under normal conditions, 
and, as we will show later, several factors are to be con- 
sidered in connection with the changes in the blood follow- 
ing removal of the pathological spleen. 

II. INCREASED RESISTANCE OF RED BLOOD CELLS 

Early in our work with splenectomized animals it was 
found that they are more resistant to haemolytic poisons 
than are normal animals. This fact had previously been 
observed in the dog by Bottazzi, 53 Banti, 28 Pugliese and 
Luzzatti , 364 and Joannovics, 200 while Domenici 95 found it 



EXPERIMENTAL STUDIES 39 

true also of the rabbit. Evidence of the increased resist- 
ance was based on the fact that to get the full toxic effect 
of a hemolytic poison it was necessary to give a splenecto- 
mized dog doses two or three times greater than were re- 
quired for the normal dog. As a result of such observa- 
tions the theory was advanced that the spleen was concerned 
in some way in influencing the normal destruction of aged 
and effete erythrocytes, and that, as this influence was 
lost after splenectomy, hemolytic agents were correspond- 
ingly less effective. This was the basis of Bottazzi's theory 
of the spleen as a haemocatatonistic (i.e., preparing red 
blood-cells for destruction) organ, which was later adopted 
by Banti and supported to some extent by Joannovics. 
Pugliese and Luzzatti, 364 on the other hand, denied the 
influence of the spleen, and pointed to the presence, in 
experimental anaemia due to pyrodin, of newly- formed im- 
mature corpuscles, poor in haemoglobin and frequently 
nucleated, which they thought might be more resistant to 
pyrodin than were the normal corpuscles and in this way 
responsible for the lesser degree of haemolysis. 

The first definite demonstration of a change in the red 
cells was made by Bottazzi, who, experimenting on dogs, 
found that the red cells after splenectomy showed an in- 
creased resistance to haemolysis in hypotonic salt solutions. 
This increase first appeared a few days after operation, 
and increased gradually up to a certain point, where it 
stayed indefinitely. He considered three possibilities: 
that the increased resistance was due (1) to the anaemia 
following splenectomy, (2) to more resistant young cells 
from a rapidly proliferating bone-marrow, (3) that the 
spleen has a special function to weaken certain red blood- 
cells. From various controls he deduced that the last 



40 THE SPLEEN AND ANAEMIA 

theory was correct, and upon this based his theory of the 
spleen as a hsemocatatonistic organ. 

At about the same time Domenici 95 showed that under 
similar circumstances the erythrocytes of the rabbit pos- 
sessed an increased resistance. It is only within the last 
five or six years, however, that definite measurements of 
the resistance of the corpuscles have been made and thereby 
the degree of increased resistance clearly established. 

Brissaud and Bauer, 59 working with two rabbits and 
using hypotonic solutions of varying strengths, found a 
decreased resistance of the red cells during a period of 
eight to ten days after splenectomy, with, after this lapse 
of time, a return to normal but no increase in resistance; 
they did not, however, continue their tests for periods of 
more than ten da}^s. Similar negative results were ob- 
tained by Biagi 45 in dogs. Chalier and Charlet, 71 testing 
both the rabbit and the dog by the salt solution method, 
concluded that splenectomy is followed by a slight increase 
in the resistance of the red cells. 

Pel, 340a in a very extensive study, found as an average 
of fifty-eight determinations that in normal dogs the first 
trace of haemolysis occurred in 0.42 per cent, salt solution, 
as compared with 0.35 as the average for thirty observa- 
tions on splenectomized dogs; the average concentration 
at which haemolysis was complete was, for normal dogs, 
0.30 per cent, salt solution, and for splenectomized dogs 
0.23 per cent. Thus in both series of observations the 
increased resistance of the splenectomized animals was the 
equivalent of 0.07 per cent, salt solution. The difference 
may be expressed in another way: in the forty-eight 
observations on normal animals haemolysis began in all 
except one test in solutions of 0.48 to 0.40 per cent., while 



EXPERIMENTAL STUDB 41 

of thirty observations on splenectomized animals, in all 
but two it began in solutions of 0.38 to 0.30 per cent. The 
resistance of the red cells was found to increase gradually 
and to reach its maximum at the end of about two months; 
after further lapse of time up to two years and four months 
there was no tendency to return to normal. Pel makes a 
general statement concerning the influence of the serum, 
to the effect that the serum of a splenectomized dog added 
to the red cells of a normal dog does not increase the re- 
sistance of the latter to hypotonic salt solution, and. vice 
vena, that the addition of normal serum to the red cells 
of a splenectomized dog does not decrease their resistance. 
Blood counts showed a slight decrease in the number 
of red cells after splenectomy, but not enough, in the 
opinion of Pel. in view also of only slight changes in the 
percentage of ha?moglobin. to indicate a relation to the 
increased resistance of the red cells. As for the fac- 
tors responsible for the increased resistance, Pel offers no 
explanation. 

Very recently Gates 13 ~ has demonstrated that the red 
blood-cells of splenectomized animals are more resistant 
than are those of normal animals when submitted to the 
mechanical damage of long-continued shaking. 

The increased resistance of splenectomized animals to 
blood poisons we observed early in our work with ha?moly- 
tic serum, 535 and as a result of occasional tests with hypo- 
tonic solutions of sodium chloride we reached the tentative 
conclusion that it was due, in part at least, to increased 
resistance of the red cells. This supposition we confirmed 
in a special study, 29 in which the cells were tested not only 
against various strengths of salt solution but by the accu- 
rate methods of immunology against specific hemolytic 



42 THE SPLEEN AND ANAEMIA 

serum, with also investigation of possible antihaemolytic 
action of the serum and changes in complement content. 

In these tests six dogs were used. One had been 
splenectomized ten days, a second thirty days, and a third 
four months before. As the last animal had been given a 
specific hemolytic immune serum two months before, thus 
introducing a new factor, the observations on it were con- 
trolled by a fourth dog not splenectomized, which had been 
given haemolytic serum five weeks before. Two normal 
dogs were used as general controls. 

Tests With Vauying Grades of Hypotonic Salt 

Solution 
Chemically pure sodium chloride was dried for two 
hours at 170° C. and immediately weighed in amounts 
necessary to make 500 cubic centimetre volumes of salt 
solution, ranging from 0.1 to 0.5 per cent, in steps of 0.025 
per cent. In order to be sure of approximately the same 
volume of corpuscles in the anaemic as in the normal bloods, 
the gently defibrinated blood was centrifuged and the 
serum drawn off. One-tenth of a cubic centimetre of the 
corpuscular mass was measured accurately in a graduated 
pipette and placed in three cubic centimetres of each of 
the various salt solutions. Standard colorimetric scales 
for comparison were made by laking red cells with distilled 
water ; thus the laking of 0.4 of a cubic centimetre of the 
corpuscular mass in twelve cubic centimetres of distilled 
water represented a standard of 100 per cent, haemolysis. 
Dilutions of this solution were made so as to have tubes 
showing the color values of 80, 60, 40 and 20 per cent, 
haemolysis. Less than 20 per cent, haemolysis was con- 
sidered as a trace of haemolysis. In most instances this 



EXPERIMENTAL STUDIES 



43 



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44 THE SPLEEN AND ANEMIA 

scale was entirely satisfactory, but occasionally, although 
a tube showed 100 per cent, haemolysis colorimetrically, 
there was, on shaking, a slight macroscopic sediment of 
incompletely haemolyzed corpuscles; this result was indi- 
cated by a minus sign after the approximate percentage 
of haemolysis. Upon adding the corpuscles to the salt 
solution, a preliminary reading was made and the mixtures 
were placed in the refrigerator. The final readings were 
made at the end of eighteen hours. The results are shown 
in Table XII. 

It will be seen that the blood of the normal dogs (30 
and 53) shows haemolysis in fairly high percentages of 
salt solution, but that the resistance, both maximum and 
minimum, is increased in all the splenectomized animals. 
It is true that dog 46, a splenectomized animal, shows 
initial haemolysis in the same percentage of salt solution 
as normal dog 53, but inspection will show that, whereas 
in the normal dog haemolysis is complete at 0.350 per cent., 
it is not complete in dog 46 until 0.300 per cent, is reached. 
There can be no doubt that the cells of dog 24, the animal 
which had been longest splenectomized, show the greatest 
degree of resistance. That this resistance is due for the 
most part, if not entirely, to splenectomy is, in view of 
results with bloods 30 and 53, most probable. On the 
other hand, it is evident, as shown by the experience with 
blood 43, that in a non-splenectomized animal the adminis- 
tration of a haemolytic immune serum is capable of causing, 
after a considerable interval, an increased resistance of 
the red cells. 



EXPERLMEXTAL STUDIES 45 

Tests With Hemolytic Immune Sebum 

In order to determine the resistance of the corpuscles 
to a specific haemolytic immune serum, the following tech- 
nique was employed: The corpuscles were washed three 
times in 0.85 per cent, salt solution, and blood suspensions 
were made of 5 per cent, of red cells as contained in the 
centrifuged corpuscular mass. The latter rather than 
whole blood was used because the use of whole blood 
would be fallacious in the case of anaemic animals. The 
immune serum was titrated against normal corpuscles, 
guinea-pig complement was used in doses of 0.1 of a cubic 
centimetre, and the experiment arranged as indicated in 
Table XIII. 

Technical limitations prevent, in this experiment, as 
close an estimation of resistance as is possible with hypo- 
tonic salt solution, but it can be seen readily that, whereas 
dilutions of 1 20 and 1 50 produce complete haemolysis 
of normal corpuscles, the corpuscles of the abnormal ani- 
mals were resistant to these dilutions. That the corpuscles 
of dog 24. which had been splenectomized four months 
previously, were most resistant is shown by the fact that 
whereas partial haemolysis appeared in all other corpuscles 
in dilutions of 1 2 50 and 1 '300, the corpuscles of this 
dog completely resisted haemolysis at such dilutions. The 
results with the blood of dog 43 demonstrate again that 
the administration of a haemolytic serum increases the re- 
sistance of the red cells, irrespective of splenectomy. 

The results with washed corpuscles in these experi- 
ments would indicate that the increase in resistance is a 
property- of the corpuscles themselves, and not the result 
of antihaemolytic power of the serum, but, to prove this 



46 



THE SPLEEN AND ANEMIA 





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EXPERIMENTAL STUDIES 47 

absolutely, other tests were made. These showed con- 
clusively that the increased resistance in splenectomized 
animals is not due to changes in complement value or 
increased antihamiolytic power of the serum. The latter 
point is brought out in the following table, in connection 
with which it must be pointed out that, as shown by Kars- 
ner and Pearce 209 in another place, normal dog serum 
has an antihaemolytic property in a homologous hemolytic 
system. This, however, is not increased in the splenecto- 
mized animal. 

It is seen that in all the dilutions of dog serum used 
the action of one dose of amboceptor and of complement 
was hindered, but in none of the dilutions was the anti- 
haemolytic property sufficient to hinder the action of two 
doses of complement and of amboceptor. Weaker dilu- 
tions were not considered necessary, because it seems cer- 
tain that between the action of a dilution of 1 64 on 
one dose of hemolysin and of whole serum on two doses 
no fine gradation could exist. 

Tests With Saponin 
In a third series of experiments we have investigated 
the resistance of the red cells to saponin. This was done 
because of the objection raised by McXeil 264 that resist- 
ance tests with hypotonic salt solution give results differ- 
ent from those obtained when the washed cells are tested 
with saponin. By immersing the cells in hypotonic salt 
solution, thereby introducing a complicating factor, he 
found that their subsequent resistance to hypotonic solu- 
tions was changed, but not their resistance to saponin. 
He concludes that saponin tests the resistance of the cell 



48 



THE SPLEEN AND ANJEMIA 





















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EXPERIMENTAL STUDIES 49 

envelope and hypotonic salt solution tests the concen- 
tration of salts inside the cell, a condition that, according 
to him, is not affected in disease. 

Our methods have been as follows: 

Saponin (Merck's Saponin Purum) was prepared in 
normal salt solution (0.85 per cent.) in strengths (varying 
by 0.0025 gm.) from 0.005 to 0.030 gms. per litre. As 
all the tests were performed and completed during a period 
of a few days, the factor of deterioration of the solution 
was avoided. In every case blood was drawn from a 
vein by means of a syringe and the red cells washed three 
times in normal salt solution. One-tenth cubic centimetre 
of a 50 per cent, suspension of such cells was added to 11 
tubes of graded strengths of saponin solution and the 
amount in each made up to 2 c.c. with normal salt solution. 
To a parallel series of 11 tubes of hypotonic salt solution 
varying in concentration from 0.25 per cent. Nad to 0.55 
per cent. NaCl equal amounts of the washed red blood- 
cells were added, and both saponin and salt solution series 
were incubated for two hours at 37.5° C, with occasional 
gentle agitation. At the end of two hours the different 
degrees of haemolysis were determined. In each series sev- 
eral tubes in the middle showed partial haemolysis, with 
complete haemolysis at one extreme and none at the other; 
so that accurate comparison could be made without resort- 
ing to the enumerative method employed by McNeil. 

By this method it was found that the red cells of sple- 
nectomized animals exhibit the same increase in resistance 
to saponin haemolysis that was observed in the experiments 
with hypotonic salt solutions and haemolytic immune serum. 
Comparative tests using hypotonic salt solution showed 



50 THE SPLEEN AND AN32MIA 

that the changes, both in maximal and minimal resistance, 
were the same as were obtained with saponin. 

These studies on the resistance of red blood-cells con- 
firm the results of others who have used graded hypotonic! 
salt solutions as a means of measuring the resistance of 
red cells and add new facts concerning the degree of resist- 
ance to specific hemolytic immune serum and to saponin. 
The second group of experiments indicates, as far as it 
is possible, by immunological methods, that the increased 
resistance is a property of the red cells themselves, and 
not the result of increased antihaemolytic power of the 
serum. 

Since these observations were made, Kolmer 222 has 
demonstrated that the erythrocytes of splenectomized dogs 
show an increased resistance also to haemolysis by cobra 
venom. This increased resistance was observed as early 
as four days after splenectomy and usually persisted for a 
period of about three weeks, when the resistance gradually 
decreased to the normal or slightly beyond. His control 
experiments show, moreover, that the temporary character 
of this increase in resistance is peculiar to venom and 
differs from the increased resistance to hypotonic salt solu- 
tions which persists for long periods of time. The in- 
creased resistance to hypotonic salt was constantly present 
in all the dogs he tested. 

To what is this increased resistance due? That it is a 
concomitant of the anaemia following splenectomy and 
occurs also in many anaemias without splenectomy is gen- 
erally admitted. It is but natural, therefore, that some 
investigators should ascribe the increased resistance to the 
presence in the blood of a large number of newly- formed 
red blood-cells, generally supposed to be more resistant 






EXPERIMENTAL STUDIES 51 

than the mature forms. This view, as we have seen, was 
first put forth by Pugliese and Luzzatti (1900) and has 
considerable support. Our own experience leads us to 
believe that the increased resistance is closely related to 
the anaemia, or to the process of repair that accompanies 
the anaemia; but, on the other hand, we have not found 
that the anaemia of splenectomy is characterized by the 
presence in the blood of cells of immature type as nucleated 
cells, or by an appreciable increase in the so-called reticu- 
lated or skeined cell, which are now considered as recently 
formed of young cells. 

We have examined many animals for these cells at 
periods varying from four days to one year after splenec- 
tomy, 339 but have failed, as a rule, to find an appreciable 
increase, and never more than 2 per cent. Moreover, 
Pepper and Peet 343 have found that in experimental 
anaemia ( in the rabbit ) due to phenylhydrazine these cells 
are no more resistant to haemolysis by hypotonic salt solu- 
tion than are normal red cells. It has therefore been 
impossible for us to bring forth definite evidence that this 
increased resistance of the cells after splenectomy is due 
to the presence of young forms. On the other hand, in 
view of the fact that this phenomenon is present in anaemia 
in animals with intact spleen, we are not prepared to 
eliminate anaemia entirely as a factor. Banti, 29 however, 
denies the influence of anaemia. He argues that (1) the 
degree of increase in resistance is not proportional to 
the anaemia, (2) it may develop in the absence of anaemia, 
(3) it may persist for many years, and (4) that red cells 
in the splenic vein are less resistant than those in the gen- 
eral circulation. He also makes the point (5) that after 
the injection of haemolytic serum, in spite of the marked 



52 THE SPLEEN AND ANAEMIA 

anaemia and the many young cells in the circulation, the 
resistance to this poison is decreased, not increased. 
Our opinion on these points is as follows: 

1. Although we believe that the increased resistance 
is closely associated with the anaemia and may probably be 
due to some factor accompanying it or the initial regenera- 
tive processes in the blood, we have not committed our- 
selves absolutely to this view, as Banti seems to think we 
have, for the reason that we have never been able to obtain 
satisfactory proof on this point. We do not, however, 
consider Banti's objection to be very substantial, for, 
although it is quite true that the degree of anaemia arising 
in a splenectomized animal is not always proportional to 
the increase in resistance, there is no reason to assume that 
there should be a proportional relation. 

2. Banti's observations concerning increased resistance 
in the absence of anaemia are not conclusive. We have 
never failed to find a decrease of red cells and haemoglobin 
at some time after splenectomy; this may come early or 
may be late, but in our experience it never fails, and, 
though as a rule long continued, may be slight and evan- 
escent. It may, however, easily be missed if continued 
counts are not made at frequent intervals for long periods 
of time. In Banti's experiments the four animals that 
failed to develop anaemia, but did show increased resist- 
ance, were examined on ( 1 ) the second and twenty-fourth, 
(2) the third and thirteenth, (3) the third and fifteenth, 
and (4) the fifth and twenty-seventh days, respectively. 
Our experience has shown that in dogs on special diets 
the change in the blood may be long delayed or may be 
present in slight evanescent form in the interval periods. 
On the other hand, in some dogs we have found occasion- 



EXPERIMENTAL STUDIES 53 

ally a slight increase of resistance before the frank fall 
in the number of red cells, but, as it coincided with or was 
quickly followed by a decrease in hsemoglobin, we could 
not rule out the influence of the factors causing anaemia. 

3. So, also, the observation concerning increased resist- 
ance in man eight years after splenectomy is inconclusive, 
for Banti's blood examination shows 4,950,000 red cells 
and 70 per cent, hsemoglobin, a figure for hsemoglobin, of 
doubtful interpretation. Much more work, both experi- 
mental and clinical, must be done before we can reach a 
definite conclusion concerning the points here discussed. 

4. The observations concerning the lessened resist- 
ance of cells in the splenic vein are offered in support of 
Banti's theory* of the spleen as an organ concerned in 
hsemolysis. While we believe the spleen is concerned in 
the destruction of red cells, our observations do not confirm 
the experiments put forth by Banti to prove the decreased 
resistance of cells of the splenic vein blood. This w T ill be 
discussed elsewhere,! as will also, in that it brings in a 
new factor, the matter of (5) decreased resistance of red 
cells immediately after the injection of a hsemolytic serum. 

Although we offer these statements to support the 
possibility of an association between ansemia and increased 
resistance, we do so without presenting definite proof. 
Moreover, we do not base this support, though Banti seems 
to think we do, on the presence of young cells in the blood. 

* Based on Bottazzi's theory that the spleen has special (haemo- 
catatonistic) action upon red blood-cells as they pass through the organ 
and as a result of which they became less resistant. The absence of 
the spleen, according to this theory, does away with this action, and 
the red cells therefore are more resistant in splenectomized animals. 

f See page 87. 



54 THE SPLEEN AND ANEMIA 

The skeined cells we have shown are no more resistant than 
are the mature cells. We do think, however, that it is 
some factor intimately associated with the causation or 
repair of the anaemia following splenectomy, and not the 
mere absence of the spleen, that is responsible for the in- 
creased resistance, and that this factor is operative in other 
anaemias, in the presence of the spleen. That this factor 
may be entirely independent of the anaemia we willingly 
admit. 

III. LESSENED TENDENCY OF HEMOLYTIC AGENTS 
TO CAUSE HEMOGLOBINURIA AND JAUNDICE 

AFTER SPLENECTOMY 
In the preceding section we have presented the evidence 
concerning the increased resistance of the erythrocytes 
as determined by the behavior of these cells to various 
lytic agents. In the present section we offer the evidence 
concerning the closely related phenomenon — the lessened 
tendency to hsemoglobinuria and icterus — exhibited by 
splenectomized dogs. To establish this point we have ex- 
amined the urine for haemoglobin and bile-pigment 335 ' 
339 and determined the changes in the blood as shown by 
red-cell counts and haemoglobin estimations. 336 The 
haemolytic agent used in every instance has been hemo- 
lytic immune serum.* 

Female dogs were used almost exclusively in order 
that the tests for haemoglobin and bile might be made on 
urine obtained by catheterization. All operations were 
under ether anaesthesia, as were also the injections of serum. 

* Rabbits were injected five times with five to ten cubic centimetres 
of dog's blood at intervals of five to seven days and bled about one 
week after the last injection. 






EXPERIMENTAL STUDIES 



55 



The injections were either into a small vein of the leg or 
into the jugular vein. Each experiment on a splenecto- 
mized animal was controlled by the injection of a normal 
animal with the same serum. When the animals were of 
approximately the same w T eight they received the same 
amounts of serum ; but when the weight varied more than 
half a kilo they received, with a few exceptions, corre- 
sponding doses per kilo, of body weight. 

The urine of all animals was examined for coagulable 
protein, hsemoglobin, and bile pigment. For the diagnosis 
of jaundice, the appearance of bile-pigment in the urine 
has been deemed sufficient. Table XV shows the effect 
of a weak hemolytic serum, administered three days after 
splenectomy. 

TABLE XV 

Effect of Hemolytic Serum Administered Three Days After Splenec- 
tomy, With Control 



Date 


Dog 11. Weight 10,000 gm. 


Dog 13. Weight 8,990 gm. 


Dec. 11, 1911 


Splenectomy 


Control 


Dec. 14, 1911 


Urine normal; 2.5 c.c. haemo- 


Urine normal; 2.5 c.c. haemo- 




lytic serum in vein 


lytic serum in vein 


Dec. 15, 1911 


Urine normal 


Bile test positive; no haemo- 
globin, no albumin 


Dec. 16, 1911 


Urine normal; 4.5 c.c. of same 


Bile test positive; no haemo- 




serum in vein 


globin, no albumin; 4.5 c.c. of 
same serum in vein 


Dec. 17, 1911 


Trace of albumin; no bile, no 


Bile test positive ; albumin pres- 




haemoglobin 


ent, no haemoglobin 


Dec. 18, 1911 


Trace of albumin; no bile, no 


Bile test positive ; albumin pres- 




haemoglobin 


ent, no haemoglobin 


Dec. 19, 1911 


Trace of albumin; no bile, no 


Bile test positive; albumin pres- 




haemoglobin 


ent, no haemoglobin 




Ligation of common bile duct 


Died, under ether, during oper- 




under ether anaesthesia 


tion to remove spleen 


Dec. 20, 1911 


Bile-pigments in urine 




Dec. 21-22, 






1911 


B ile-pigment s in urine increasing 




Dec. 23, 1911 


Bile-pigment s in urine in creasing 
Killed by chloroform 





56 



THE SPLEEN AND ANAEMIA 



In this experiment the hemolytic serum was not power- 
ful enough to cause a destruction of blood of sufficient 
grade to produce hemoglobinuria, although it did cause 
in the control animal enough destruction to produce jaun- 
dice; on the other hand, the splenectomized animal was 
free from jaundice. 

The objection might be raised, in connection with this 
experiment, that the jaundice of the control animal might 
be due to the fact that, as the smaller of the two animals, 
it received a relatively larger dose of serum. This objec- 
tion is not tenable, as is shown by Table XVI. In the 
experiment here presented, a stronger serum was used and 
the amount injected was adjusted to the weight of the 
animals. 

TABLE XVI 

Effect of Hemolytic Serum Six Days After Splenectomy, With 

Control 



Date 



Dec. 14, 1911 
Dec. 20, 1911 

Dec. 21, 1911 

Dec. 22, 1911 

Dec. 23, 1911 

Dec. 24, 1911 

Dec. 25, 1911 

Dec. 26-27, 

1911 
Dec. 28, 1911 
Dec. 29, 1911 



Dog 3. Weight 6,400 gm. 



Splenectomy 

Urine normal 

0.5 c.c serum per kilo. 

Hemoglobinuria; no bile-pig- 
ment 

Hemoglobinuria; no bile-pig- 
ment 

Hemoglobinuria; no bile-pig- 
ment 

Trace of hemoglobinuria; no 
bile-pigment 

No hemoglobinuria; no bile- 
pigment 

Faint trace of bile-pigment 
No bile-pigment 
No bile-pigment 



Dog 7. Weight 10,580 gm. 



Control 

Urine normal 

0.5 c.c. serum per kilo. 

Hemoglobinuria; marked jaun- 
dice 

Hemoglobinuria; marked jaun- 
dice 

No hemoglobinuria; marked 
jaundice 

No hemoglobinuria; marked 
jaundice 

No hemoglobinuria; marked 
jaundice 

Much bile-pigment in urine 
Much bile-pigment in urine 
Much bile-pigment in urine 



EXPERIMENTAL STUDIES 



51 



That the same results are obtained after longer periods 
of time have elapsed is shown in Table XVII, which pre- 
sents the results obtained sixty-five days after splenectomy. 

TABLE XVII 
Decreased Tendency to Jaundice Sixty-five Days After Splenectomy 



Date 


Dog 10. Weight 9,720 gm. 


Dog 22. Weight 6,710 gm. 


Dec. 9, 1911 


Splenectomy 


Control 


Feb. 12, 1912 


Urine normal 


Urine normal 


Feb. 13, 1912 


0.25 c.c. serum per kilo . into vein 


0.25 c.c. serum per kilo, into vein 


Feb. 14, 1912 


Urine free from haemoglobin 


No hemoglobinuria; bile-pig- 




and bile-pigment 


ments present 




1 c.c. same serum per kilo, into 


1 c.c. per kilo, of same serum into 




vein 


vein 


Feb. 15, 1912 


No hemoglobinuria; no bile- 


Marked hemoglobinuria; much 




pigment 


bile-pigment 


Feb. 16, 1912 


No hemoglobinuria; no bile- 


No hemoglobinuria; much bile- 




pigment 


pigment 




2 c.c. per kilo, of another serum 


No third injection. Spleen ex- 




into vein 


cised 


Feb. 17, 1912 


Hemoglobinuria; faint trace of 

bile-pigment 
No hemoglobinuria; faint trace 

of bile (?) 
No hemoglobinuria; faint trace 

of bile (?) 
Common bile-duct ligated 


Well marked bile reaction 


Feb. 18, 1912 


Well marked bile reaction 


Feb. 19, 1912 


Well marked bile reaction 






Feb. 20-21, 


Large amount of bile-pigment 


Well marked bile reaction 


1912 


in the urine 






Chloroformed 


Chloroformed 



In all of these experiments the splenectomized dogs 
show less tendency to jaundice and usually to hsemoglo- 
binuria than do the normal dogs with corresponding doses 
of the same hemolytic serum, and this, as will be shown 
later, we have found to be characteristic of animals that 
have been splenectomized for various periods up to one 
year. Beyond that period we have made no observations. 



CHAPTER III 

CONCERNING THE SUPPOSED REGULATORY INFLUENCE 

OF THE SPLEEN IN BLOOD DESTRUCTION 

AND REGENERATION 

A. IN RELATION TO THE DECREASED TENDENCY 
TO HEMOGLOBINURIA AND JAUNDICE: (1) THE 
RELATION OF SPLEEN TO THE LIVER AND THE 
FORMATION OF BILE FROM HEMOGLOBIN. (2) 
THE INFLUENCE OF THE COURSE OF THE BLOOD 
TO THE LIVER. (3) THE INFLUENCE OF ANEMIA. 
(4) THE INFLUENCE OF THE INCREASED RESIST- 
ANCE OF THE RED CELLS. (5) ARE SPLENIC EX- 
TRACTS HEMOLYTIC? (6) POSSIBLE INFLUENCE 
OF FATTY ACIDS AND LIPOIDS. 

In the preceding chapters have been presented the 
three most important phenomena — ansemia, increased re- 
sistance of the erythrocytes, and decreased tendency to 
jaundice — which follow splenectomy. A discussion of 
these involves a presentation of the literature and of ex- 
periments dealing with the supposed regulatory influence 
of the spleen. As the increased resistance of the red cells 
has a relation both to the problem of anaemia and to that 
of the decreased tendency to jaundice, it will not be dis- 
cussed separately, but in relation to each of these. 

How does the absence of the spleen influence the oc- 
currence of hemoglobinuria and jaundice? 

(1) One improbable explanation, that the absence of 
the spleen prevents the secretion of bile by the liver, may 
be dismissed immediately, for, as shown in Tables XV and 
XVII, the ligation of the bile-duct in the splenectomized 

58 



REGULATORY INFLUENCE OF THE SPLEEN 59 

animal :; ^ causes the appearance of bile in the urine within 
twenty-four hours. On the other hand (Table XVII), 
the excision of the spleen in an animal with hemolytic 
jaundice does not immediately lessen the elimination of 
bile through the urine. 

Does the spleen take part in the formation of bile- 
pigment from haemoglobin? As the solution of this prob- 
lem necessitated the study of haemoglobinaemia in normal 
animals, we undertook an extensive investigation 334 under 
the following heads: (1) The degree of haemoglobimrmia 
necessary in order to recognize free haemoglobin in the 
serum; (2) the degree of haemoglobinaemia necessary for 
the escape of haemoglobin through the kidneys: (3) the 
percentage of haemoglobin eliminated by the kidneys; (4) 
the degree of retention of haemoglobin necessary to cause 
jaundice; (5) the influence of the absence of the spleen on 
the elimination or retention of haemoglobin and the occur- 
rence of jaundice. 

Methods 

Deflbrinated dog blood was haemolyzed with distilled 
water, sodium chloride was added to render the solution 
isotonic with dog blood, the haemolyzed blood was centrifu- 
galized to remove the stroma, and the haemoglobin content 
was then determined with a Fleischl haemoglobinometer. 
Definite amounts of the haemoglobin solution, always 
freshly prepared, were allowed to flow from a burette into 
a small branch of the femoral vein. The first appearance 
of haemoglobin in the urine was determined by a catheter 
in the bladder or by a catheter in one ureter. In order 
to aid the flow of urine, each dog received 300 cubic 
centimetres of water by stomach-tube. From time to time 
the skin was punctured and blood was drawn into capillary 



60 THE SPLEEN AND ANEMIA 

tubes to determine how early free haemoglobin appeared 
in the serum. 

The elimination of haemoglobin in the urine was esti- 
mated by rendering the urine acid with hydrochloric acid 
to about N/10 and comparing this solution of acid haema- 
tin, suitably diluted, with a 1 per cent, solution made 
according to the Sahli method from blood containing 100 
per cent, of haemoglobin by the Fleischl scale. A Dubosc 
colorimeter was used for making the comparison. 

The quantities of haemoglobin are designated in the 
table (Table XVIII) in grammes, calculated on the 
assumption, for the sake of convenience, that blood giving 
a reading of 100 per cent, by the Fleischl scale contains 
14 per cent, of haemoglobin. This figure is, of course, only 
approximately correct, but, as only relative quantities are 
of importance in this work, an approximate determination 
of the absolute quantities of haemoglobin is sufficient. 

In order to determine quantitatively the amount of 
haemoglobin which must be retained in order to cause jaun- 
dice, decreasing amounts of haemolyzed blood were injected 
intravenously into a series of normal dogs; in each case 
the percentage elimination by the kidney and occurrence 
or non-occurrence of bile-pigment in the urine were noted. 

The results of these experiments are shown in Experi- 
ments I to IX in Table XVIII. 

It is seen (Experiments II, VI, VII, VIII, IX) that 
the retention of 0.39 gramme of haemoglobin per kilo, 
caused marked choluria; of 0.23 gramme, slight choluria 
for twenty-four hours; and of 0.22 gramme, a very faint 
choluria for eight hours; the retention of 0.18 and 0.19 
gramme per kilo, of body weight failed to cause choluria. 

The percentage of haemoglobin eliminated by the kid- 



REGULATORY INFLUENCE OF THE SPLEEN 



61 





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62 THE SPLEEN AND ANAEMIA 

ney appears to be a variable quantity. Thus, in Experi- 
ment VI, 32.5 per cent, of the haemoglobin injected was 
eliminated by the kidney; in Experiment VII, 26.8 per 
cent.; in Experiment VIII, 17.1 per cent.; in Experiment 
IX, 35.9 per cent. 

In these four experiments the haemoglobin solution 
was rapidly injected during a period of from four to thir- 
teen minutes. When the solution was introduced more 
slowly a much larger amount could apparently be cared 
for in the liver without the production of jaundice. Thus, 
if we refer again to Table XVIII, Experiment I, in which 
the solution was introduced at intervals throughout a 
period of fifty-six minutes, we find that an amount of 
haemoglobin was retained equal to 0.33 gramme per kilo., 
without bile-pigments occurring in the urine. 

These experiments seem definitely to establish the 
mechanism by which free haemoglobin is removed from the 
blood-serum under normal conditions. Our conception of 
this mechanism is as follows: The kidney does not elim- 
inate haemoglobin until its concentration in the blood-serum 
reaches a certain level. This concentration, we conclude 
from Experiments I, II, III, is about that produced by 
the presence of 0.06 gramme of free haemoglobin per kilo, 
of body weight. As soon as the concentration of the haemo- 
globin in the serum is above this point, the haemoglobin 
passes through the kidneys and we have haemoglobinuria, 
but as soon as it falls below this amount, the haemoglobin- 
uria ceases. However, other tissues, of which presumably 
the liver is the most important, appear to take up haemo- 
globin as soon as mere traces are present in the serum, 
and continue to remove it from the serum, whether the 
renal threshold is exceeded or not. Therefore, whenever 



REGULATORY INFLUENCE OF THE SPLEEN 63 

the kidney is removing haemoglobin from the serum, these 
other tissues are also removing it. Under the conditions 
of these experiments the kidneys removed 17 to 36 per 
cent., and the liver (and other tissues?) 64 to 83 per cent. 

The haemoglobin which the liver removes is changed 
into bile-pigment, which, if it is not produced in too large 
amounts, or if the haemoglobin is not taken to the liver too 
rapidly, passes out as bile-pigment in the usual manner 
through the bile-passages. On the other hand, if the haemo- 
globin is taken up by the liver in larger quantities, and 
especially if this occurs rapidly, the bile-pigment is formed 
faster than the bile capillaries can remove it, and it is re- 
absorbed into the circulation and appears in the urine. 

The effect of splenectomy on this process was deter- 
mined in part by observations on the same animal before 
and after splenectomy, and in part on animals splenecto- 
mized for various lengths of time (Table XVIII, Experi- 
ments X to XV). 

These six experiments on splenectomized animals, in 
all of which bile-pigments appeared in the urine for a 
short time and in small quantities after the retention of 
0.44, 0.31, 0.25, 0.28, 0.26, and 0.22 gm. per kilo., re- 
spectively, indicate that the threshold for jaundice in 
splenectomized dogs is approximately 0.22 gramme per 
kilo., the same as in the experiments (VI to IX) with 
normal dogs, in which the threshold was found to be be- 
tween 0.18 and 0.22 gramme per kilo. 

When we examine the percentage of haemoglobin elim- 
inated by the kidneys in the six splenectomized animals, 
we find that it runs a trifle lower than the limits deter- 
mined for normal animals, being 18.8, 16.8, 21.1, 27.5, 7.2 
( ?) , and 18.4 per cent, (average, excluding the fifth figure, 



64 THE SPLEEN AND ANEMIA 

20.& per cent.) , as compared with 82.5, 26.8, 17.1, 35.9, 
16, and 26.5 per cent. (Experiments VI to XI), with 
an average of 25.8 per cent. This difference is, however, 
so slight that we can conclude that splenectomy has no 
influence in increasing the elimination of free haemoglobin 
by the kidneys, nor does it, as is shown by the occurrence 
of choluria in each of the experiments, influence the ability 
of the liver to form bile-pigments from haemoglobin, or 
interfere with the elimination of these pigments. Thus 
one of the possible explanations for the failure of jaundice 
to follow the administration of a hemolytic serum in sple- 
nectomized animals is shown to be untenable. 

(2) The Influence of the Course of the Blood to 

the Liver 

Although the experiments described in the preceding 
section led to negative conclusions, there is another possible 
factor, a purely mechanical one ; that is, the relation of the 
spleen to the blood supply of the liver. Inasmuch as the 
spleen is undoubtedly a seat of destruction of red cells, the 
splenic blood must carry to the liver haemoglobin in larger 
amounts, or more concentrated, than does the blood reach- 
ing the liver through the hepatic artery in the absence of 
the spleen. This difference in haemoglobin content, under 
the conditions mentioned, might be sufficient to explain, in 
a purely mechanical way, the lessened tendency to jaun- 
dice after removal of the spleen. This possibility was 
investigated in two groups of experiments : in one 23 haemo- 
globin was injected in the general circulation (femoral 
vein) and into portal circulation (mesenteric vein), and 
the influence of these two procedures on the occurrence of 
hemoglobinuria and jaundice was studied. In another 229 



REGULATORY INFLUENCE OF THE SPLEEN 65 

set of experiments the blood from the spleen was diverted 
from the liver by ligation of the splenic vein, as well as by 
an Eck fistula or an anastomosis of the splenic vein with 
the vena cava, and the occurrence, under these conditions, 
of jaundice due to the administration of hemolytic agents 
was studied. 

In connection with this problem it may be recalled that 
Ponfick 358 applied the term " spodogenous " (pnohoc, 
waste products ) to the spleen of haemolysis, swollen in con- 
sequence of the accumulation of disintegrating erythro- 
cytes, and that he noted that simultaneously the liver elim- 
inates a bile very rich in pigment, and suggested that this 
latter is derived from the haemoglobin set free in the spleen, 
carried by the portal circulation to the liver, and removed 
by this organ. Ponfick further expressed the view, based 
on experiments not quoted in detail, that the liver could 
completely remove and transform into bile-pigment liber- 
ated haemoglobin up to the extent of one-sixtieth of the 
total haemoglobin of the body, but that haemoglobin set 
free in excess of this amount passes through the liver and 
is eliminated by the kidneys, causing haemoglobinuria. 
One-sixtieth of the total haemoglobin in the dog is about 
0.18 gm. per kilo. In the preceding section we have shown 
that the injection of 0.14 to 0.35 gm. per kilo, of haemo- 
globin as laked blood will cause the appearance of haemo- 
globinuria, but that a factor of great importance, appar- 
ently overlooked by Ponfick, is the rate at which the haemo- 
globin is liberated in the circulation. The more slowly it 
is introduced the larger is the quantity that the liver can 
take up without permitting the concentration in the blood 
to reach at any time that required for the production of 
haemoglobinuria. Also, we have shown that, while small 



66 THE SPLEEN AND ANEMIA 

amounts of injected haemoglobin are removed by the liver 
and presumably excreted as bile-pigments in the bile with- 
out the occurrence of jaundice, if the injected haemoglobin 
be in excess of 0.30 to 0.40 gm. per kilo, the liver is unable 
to eliminate all the bile-pigment formed from the excess 
of haemoglobin, and some of the bile-pigment is reabsorbed 
from the liver and under these circumstances appears in 
the urine. It was noted in this respect, also, that the rate 
of injection is of greater importance in determining the 
amount of haemoglobin that the liver will tolerate without 
the appearance of bile-pigments in the urine. Very slow 
but long- continued administration of haemoglobin can 
eventually overtax the hepatic excretory power and lead 
to the appearance of bile-pigments in the urine, although 
the haemoglobin transformation may have been slow 
enough to permit of its continued adequate removal from 
the circulation by the liver with at no time the development 
of haemoglobinuria. Thus the first effect of haemoglobin 
liberation into the blood is an increased bile pigment con- 
tent of the bile. This was shown experimentally by Tar- 
chanoff. 426 If the amount of haemoglobin be small enough 
and its liberation slow enough, this is the only effect. A 
slightly larger amount, rapidly liberated, will produce 
haemoglobinuria. A still larger amount, extremely slowly 
liberated, will produce bile in the urine. An equal amount 
liberated at an intermediate rate may produce both haemo- 
globinuria and bile-pigments in the urine. 

Following Ponfick, many other workers have attributed 
importance to the spleen as the site of disintegration of 
erythrocytes; among these may be mentioned Hunter, 189 
Gabbi, 135 and Mya. 312 Bottazzi, 53 in his studies of the 
blood after splenectomy, noted an increased resistance of 



REGULATORY INFLUENCE OF THE SPLEEN 67 

the erythrocytes to hypotonic salt solutions, and it was to 
this factor that Banti 28 attributed the greater resistance 
and diminished tendency to jaundice of splenectomized 
animals receiving hemolytic agents. 

However, Pugliese and Luzzatti 364 did not agree with 
Bottazzi, but, noting, with Banti and others, the dimin- 
ished tendency to jaundice after splenectomy, they made 
further studies along the lines suggested by Ponfick's ob- 
servations and elaborated the following hypothesis: The 
spleen is the natural location for the disintegration of ery- 
throcytes after the administration of hsemolytic poisons, 
and the haemoglobin so liberated is carried directly by the 
portal system to the liver, there to be converted into bile- 
pigment and to be excreted in the bile, or, if present in 
great quantity, to be reabsorbed and appear in the urine 
and tissues as bile-pigments and thus produce jaundice. 
On the other hand, in the absence of the spleen, the blood- 
cells undergo disintegration elsewhere, probably chiefly in 
the bone-marrow, as suggested by Martinotti and Bar- 
bacci. 277 Haemoglobin liberated in the bone-marrow could, 
under these circumstances, reach the liver only through the 
general circulation. It would therefore be diluted and, 
moreover, would reach the liver largely through the hepatic 
artery — a vessel normally carrying blood for nutritive pur- 
poses, not for purposes of elaboration. For these reasons 
it is to be expected that, in the splenectomized animal, the 
haemoglobin would reach the liver much more gradually 
and at a rate, indeed, which might well lie within the 
capacity of the liver for complete excretion as bile-pig- 
ment, and hence no reabsorption of bile-pigments would 
occur and jaundice would not develop. 

Pugliese and Luzzatti were able to show by the aid 



68 THE SPLEEN AND ANEMIA 

of a bile fistula that, while the other constituents of the 
bile are but little altered by splenectomy, the bile-pigments 
are reduced to about one-half. Moreover, while the bile 
of the splenectomized animal shows an increase in the bile- 
pigments after the administration of haemolytic poisons, 
this is not so pronounced as in the normal animal; the 
increased pigmentation of the bile is, however, of longer 
duration in the splenectomized animal. 

In order to test the hypothesis of Pugliese and Luz- 
zatti, we have injected 23 a constant amount per kilo, of 
haemoglobin solution in the form of laked blood into a series 
of dogs, injecting each at least twice — once into the gen- 
eral circulation by way of the femoral vein and once into 
the portal circulation by way of a mesenteric vein. The 
rate of injection has been always the same. In some 
instances the femoral injection was given first, in other 
instances the mesenteric. At least five days were allowed 
to elapse between injections. We have thus been able to 
study the effect of the site of the injection upon the develop- 
ment of haemoglobinuria and of bile-pigments in the urine, 
and, from our results, believe we may draw conclusions 
as to the fate of haemoglobin when liberated into the portal 
system, on the one hand, or into the general circulation, 
on the other. 

In these experiments a fasting normal dog was bled, 
the blood defibrinated, the cells thrown down by a centri- 
fuge, and the supernatant serum removed. About four 
volumes of distilled water were then added to the cells to 
induce haemolysis, and the mixture agitated for fifteen to 
twenty minutes. The solution was then centrifugalized 
rapidly for twenty minutes to remove the cell stromata, 
was made isotonic by addition of sodium chloride, and cen- 



REGULATORY INFLUENCE OF THE SPLEEN G9 

tril'ugalized to remove any globulin thrown out of solution 
upon adding the salt. One cubic centimetre of this solu- 
tion was then diluted with 99 c.c. of distilled water and 
its haemoglobin strength determined in a Fleischl-Mieseher 
hivmoglobinometer. Into a normal dog was then injected 
intravenously as much of this solution as should equal 
either 0.3 gm. or 0.4 gm. of haemoglobin per kilo, of body 
weight. Injections were given at such a rate that the en- 
tire injection should occupy one minute per kilo, of body 
weight. All bleedings and injections were made under 
ether anaesthesia. Injections into the general circulation 
were made into one of the small veins of the leg. Portal 
injections were made by drawing a loop of intestine from 
the abdomen under aseptic precautions and injecting 
through a needle into a small mesenteric vein. In some 
instances water was given by stomach-tube at the close 
of the operation. The urine was then collected, the dog 
being kept in a metabolism cage, and, if haemoglobin ap- 
peared, the amount was estimated either directly in the 
Fleischl-Mieseher haemoglobinometer or by comparison 
with a standardized acid haematin solution. In addition, 
we followed the course of the jaundice by observing the 
persistence of bile-pigments in the urine after haemoglobin 
injection into either the mesenteric or the femoral vein. 
The urine was examined for bile-pigments by the Rosen- 
bach test. 

The results as regards haemoglobinuria are shown in 
Table XIX. In each of five dogs used, the output of 
haemoglobin by the kidney was much less when the haemo- 
globin was introduced into the mesenteric vein than when 
introduced into the femoral vein, and this is true regardless 
of which injection was performed first. This we attribute 



70 



THE SPLEEN AND ANEMIA 



to the removal of the haemoglobin to a greater extent by 
the liver when the injection is made into a mesenteric vein, 
with the result that the haemoglobin reaching the general 
circulation is less concentrated and is less likely to be elim- 
inated by the kidneys and appear in the urine. 

TABLE XIX 

Influence of Site of Injection on Amount of Hemoglobin Eliminated 

in the Urine 



Haemoglobin injections 


Date 


Gm. of haemoglobin per kilo, elim- 
inated in the urine after injection 
into 




Femoral vein 


Mesenteric vein 


Dog 26 (0.4 gm. per kilo.) 


Mar. 20 
Mar. 26 
Feb. 25 
Apr. 15 
Jan. 9 
Jan. 15 
Mar. 2 
Mar. 26 
Jan. 7 
Jan. 15 
Feb. 19 
Mar. 2 
Mar. 20 
Feb. 25 
Apr. 15 


0.085 

0.043 
0.024 

0.026 
0.017 

0.025 
0.014 




Dog 12 (0.3 gm. per kilo.) 


0.043 
029 


Dog 5 (0.3 gm. per kilo.) 




Dog 3 (0.3 gm. per kilo.) 


None 
None 


Splenectomized 


Trace 


Dog 49 (0.3 gm. per kilo.) 


None 


Three months after splenectomy 


0.010 



The results of the study of the degree and persistence 
of jaundice (as indicated by bile-pigments in the urine) 
in the dogs after the two types of injection are shown 
in Table XX. 

It will be seen that in the six dogs studied, the jaundice 
was distinctly more persistent after mesenteric than after 
femoral injection, and this was true regardless of which 
injection was made first. In Dog 4 two successive injec- 
tions were made into the femoral vein to determine whether 
the second injection would give a result notably different 
from the first. Such was not the case, the duration of 



REGULATORY INFLUENCE OF THE SPLEEN 



71 



the bile-pigments being the same after each injection when 
both were made into the femoral vein. 

In our studies both of hemoglobinuria and of the per- 
sistence of jaundice after haemoglobin injections we have 
employed splenectomized as well as normal dogs, but have 
found that the mere absence of the spleen has no influ- 
ence upon the fate of hsemoglobin injected into either the 
general or portal circulation. The place of injection is 
the important factor. 

TABLE XX 

Persistence of Bile-Pigment in the Urine After Haemoglobin Injection 
as Determined by Point of Injection 





Date 


Persistence after injection into 


Hsemoglobin injections 


Femoral vein 


Mesenteric vein 


Dog 4 (0.3 gm. per kilo.) 

Dog 5 (0.3 gm. per kilo.) 

Dog 25 (0.4 gm. per kilo.) 

Dog 26 (0.4 gm. per kilo.) 

Dog 12 (0.3 gm. per kilo.) 

Dog 3 (0.3 gm. per kilo.) 

Splenectomized 


Jan. 9 
Jan. 16 
Jan. 9 
Jan. 15 
Mar. 21 
Mar. 26 
Mar. 20 
Mar. 26 
Feb. 25 
Apr. 15 
Jan 7 
Jan. 15 
Feb. 19 
Mar. 2 
Mar. 20 
Feb. 25 
Apr. 15 


days 

4 
4 
3 

4 

4 

4 




4 


days 

12 + 

7 + 

7+ 
5 

9 


Dog 49 (0.3 gm. per kilo.) 

Three months after splenectomy 


4 
6 



These experiments indicate, therefore, that when haemo- 
globin is set free in the portal circulation a larger amount 
is held by the liver and converted rapidly into bile-pigment 
than is the case when it is set free in the general circulation, 
and that under the former condition overloading of the 
liver with bile-pigment more readily occurs and jaundice 
is more apt to develop. 



72 THE SPLEEN AND ANAEMIA 

This mechanical influence must therefore be a factor, 
though not necessarily the only factor, in the lessened 
tendency after splenectomy to the jaundice which follows 
blood destruction due to hemolytic agents, for whether 
the spleen be an active factor in destroying the erythrocytes 
or whether it plays merely a passive part as a place for 
the deposition of the disintegrating cells, there can be no 
question that in this organ a large number of cells undergo 
their final disintegration after the action of hsemolytic 
poisons, and that the haemoglobin there liberated passes by 
the portal system directly to the liver. When the spleen 
is removed this disintegration occurs in other organs, nota- 
bly in the lymph-nodes and bone-marrow, and the haemo- 
globin from these organs passes not into the portal but 
into the general circulation, from which it reaches the liver 
more gradually and in a more dilute form. Jaundice is 
therefore less apt to occur under such circumstances, when 
a heemolytic agent is administered, than is the case in the 
normal animal. 

Other experiments giving essentially the same result 
and supporting the injection experiment described above 
are those* in which, by ligation of the splenic vein and 
blood-vessel anastomosis, the splenic blood was diverted 
from the liver and hemolytic agents were then adminis- 
tered. 229 These showed the same decreased tendency to 
jaundice that is shown by splenectomized animals. 

(3) The Influence of Anemia 

This we have investigated in some detail. 336 In our 
earlier work it was noticed more or less accidentally that 

* See page 130. 



REGULATORY INFLUENCE OF THE SPLEEN 73 

an injection of hemolytic serum into anaemic clogs, whether 
splenectomized or not, did not cause jaundice so readily 
as in dogs with normal red-cell count and normal haemo- 
globin content. This observation suggested that it might 
not be the mere absence of the spleen, but secondary 
changes in the blood consequent upon the absence of the 
spleen, that in addition to the mechanical factor prevented 
the appearance of jaundice in splenectomized animals. 
We therefore turned our attention to the condition of the 
blood in all splenectomized animals. 

As we have shown in the first chapter, splenectomy 
is followed by a moderate anaemia in which a decrease of 
haemoglobin is especially prominent. The lowest level of 
this anaemia corresponds to the third to the sixth week, 
and it occurred to us that, in this early period, the lessened 
tendency to jaundice might be associated in some way 
with the coexistent anaemia. Obviously it was possible to 
test this hypothesis by studying the effect of a haemolytic 
serum on dogs rendered anaemic in some other way than 
by splenectomy. This was done by bleeding, as is shown 
in an experiment (see Table XXI) in which a normal 
dog with high haemoglobin content is contrasted with a dog 
rendered moderately anaemic by bleeding. 

In this experiment the anaemic dog, although it received 
the same amount of serum, proportionately, and, on ac- 
count of its greater weight, twice as much, actually, as the 
control, failed to develop haemoglobinuria or jaundice, and 
this in spite of the fact that the actual fall in haemoglobin 
and red blood-cells was more rapid and greater than in the 
control. "Anaemia would appear, therefore, to be an impor- 
tant factor in lessening the tendency to jaundice. How 
the anaemia acts to lessen the jaundice is not indicated by 



74 



THE SPLEEN AND ANAEMIA 



our experimental data. A possible explanation which may- 
be offered, however, is the following. We have shown that 
the liver exhibits a saturation point for haemoglobin, so 

TABLE XXI 

Effect of Hemolytic Serum on a Dog Rendered Anaemic by Bleeding. 

Normal Control 



Date 



April 18, 1912 



April 20, 1912 

April 21, 1912 
10 A. M.. . . 



April 21, 1912 ; 
11.10 A.M. 



5 P.M. 



April 22, 1912 



April 23, 24, 

25, 1912 
April 24, 1912 

April 25, 1912 



Anaemic dog 



Weight, 10,740 gm. 
Urine : free of albumin 
179 c.c. of blood taken 

from jugular vein 
150 c.c. of blood taken 

from jugular vein 

Urine: no albumin, no 

bile-pigment 
Blood : red cells, 4,450, 000 ; 

haemoglobin 87 per cent . 
Fragility: 0.3 + ; 0.4- 



Received 0.25 c.c. haemo- 

lytic serum per kilo, in 

vein 
Urine: no albumin, no 

bile 
Blood :red cells, 3,400,000; 

haemoglobin 54 per cent . 

Urine: no haemoglobin, 

no bile 
Blood :red cells, 3,250,000; 

haemoglobin 49 per cent. 



Urine : no bile-pigment 
Blood: red cells, 3,040,000; 

haemoglobin 42 per cent. 
Blood :red cells, 2,910,000; 

haemoglobin 42 per cent. 



Date 



April 16, 1912 



11.45 A. M. 



2.45 P. M. 
3.15 P. M. 



6.30 P. M. 



April 17, 1912 



April 18, 1912 
April 19, 1912 



Control dog 



Weight, 5,350 gm. 

Urine: no albumin, no 
bile. 

Blood: red cells, 5,390,- 
000; haemoglobin 107 
per cent. 

Fragility: 0.4 +; 0.5 -, 

Received in vein 0.25 
c.c. per kilo, of same 
serum as anaemic dog. 

Much bile in urine. 

Blood: red cells, 5,330,- 
000; haemoglobin 98 
per cent. 

Urine: contains haemo- 
globin and much bile 

Blood: red cells, 4,660,- 
000; haemoglobin 85 
per cent. 

Urine contains haemo- 
globin and bile-pig- 
ment 

Blood: red cells, 4,470,- 
000; haemoglobin 73 
per cent. 

Urine: no haemoglobin, 
but trace of bile 

Urine : no bile, no albu- 
min 

Blood: red cells, 4,930,- 
000 



that, if haemoglobin be supplied to it in excess of a given 
amount, jaundice will result, but that, conversely, haemo- 
globin supplied to it in quantities less than this amount 
will not give rise to jaundice. Now it may well be that 



REGULATORY INFLUENCE OF THE SPLEEN 



75 



in an animal rendered anaemic either by bleeding or by 
insufficient blood formation the daily blood-cell destruc- 
tion may be less than in the normal animal and hence the 
liver be further from its normal saturation point for haemo- 
globin. In such an animal more haemoglobin could be liber- 



TABLE XXII 

Effect of Hemolytic Serum on Splenectomized Dogs with Normal Red 

Cell Count 



Date 



April 17, 1912 
April 21, 1912 

11.25 A.M. 
5.20 P.M. 



April 22, 1912 



April 23, 1912 
April 24, 1912 



Four day splenectomy 



Dat< 



Weight, 7,850 gm. 
Splenectomy 
Urine : no albumin, no bile 
Blood : red cells, 5,880, 000 ; 
haemoglobin 102percent. 
Fragility: 0.3 + ;0.45- 
Received in vein 0.25 c.c. 

serum per kilo. 
Urine : (by catheter) con- 
tains large amount of 
bile-pigment and faint 
trace of albumin 
Blood :red cells, 5,330,000; 
haemoglobin 93 per cent, i 
Urine : trace of bile 
Blood :red cells, 5,260,000 ; 
haemoglobin 81 per cent. 
Urine : faint trace of bile 
Urine : no albumin, no bile 
Blood :red cells, 4,800,000; 
haemoglobin 70 per cent. 



Feb. 10, 1912 
April 16, 1912 



12 M. 
2.45 P.M. 
3.50 P.M. 



11.00 P.M. 
April 17, 1912 



April 25, 1912 Blood: red cells, 4,510,000;; April 18, 1912 



haemoglobin 80 per cent, 



April 19, 1912 



Sixty-six day splenectomy 



Splenectomy 
Weight, 12,680 gm. 
Urine: faint trace of 

albumin, no bile 
Blood: red cells, 5,230,- 

000; haemoglobin 83 

per cent. 
Fragility : 0.25 + ; 0.35- 
Received in vein 0.25 

c.c. serum per kilo. 
Urine: trace of bile-pig- 
ment 
Blood: red cells, 5,310,- 

000; haemoglobin 84 

per cent. 
Urine: moderate amoun 

of bile-pigment 
Urine : moderate amount 

of bile-pigment 
Blood: red cells, 4,830,- 

000; haemoglobin 79 

per cent. 
Urine : no bile-pigment. 
Blood: red cells, 4,500,- 

000 
Urine: no bile. 



ated into the circulation as the result of a single insult and 
be removed by the liver without exceeding the saturation 
point of the liver and thus jaundice would not occur. 

It is therefore at once evident that if it is the presence 
of an anaemia, subsequent to the splenectomy, which is of 



76 THE SPLEEN AND ANAEMIA 

importance in preventing the development of jaundice, 
then haemolytic serum administered to an animal soon after 
splenectomy, before anaemia has developed, or long after 
splenectomy, when the blood has again returned to normal, 
should induce the appearance of the bile-pigments in the 
urine. Both these experiments were performed and the 
results tabulated in Table XXII. 

In both of these splenectomized animals bile-pigments 
appeared in the urine, and a trifle more abundantly in that 
animal which at the beginning had the higher haemoglobin 
and red blood-cell count. Thus anaemia would appear also 
to be a factor in lessening the tendency to jaundice after 
administration of a haemolytic agent. 

(4) Influence of the Increased Resistance of the 

Red Cells 
In neither of the splenectomized animals in Table 
XXII was the jaundice quite so marked as in the control 
animal given the same dose of the same serum (see Table 
XXI ) , and in neither did the hemoglobinuria occur that 
was observed in the control. The rate of fall of haemoglo- 
bin and red blood-cells in these animals shows that the rate 
of blood destruction in the control animal was much greater 
than in either of the splenectomized animals. In the ani- 
mal splenectomized four days the eventual blood destruc- 
tion equalled that of the control, but it occurred much more 
slowly; and in that splenectomized for sixty-six days the 
amount of blood destruction was relatively slight. This 
constitutes a peculiarity in the reaction of a splenectomized 
dog to haemolytic agents which necessitates detailed dis- 
cussion. The splenectomized animal may show an eventual 



REGULATORY INFLUENCE OF THE SPLEEN 77 

blood destruction, following hemolytic agents, less than, 
equal to, or greater than, the controls, but almost always 
the rate of blood destruction is slower. We believe that 
at least one factor although not the only one, in this phe- 
nomenon is the influence of the increased resistance of the 
red blood-cells. In confirmation of this it may be noted 
that in the three animals under discussion the rate of blood 
destruction was proportionate to the fragility of the red 
blood-cells. Such increased resistance of the red blood- 
cells has been shown to be characteristic of all splenecto- 
mized dogs. Consideration of the results obtained upon 
introduction of free haemoglobin into the circulation at 
various rates indicates at once the importance of a slower 
rate of blood destruction which must lead to a diminished 
tendency both to hemoglobinuria and to jaundice. Hence 
the increased resistance of the red blood-cells, in that it 
causes a slower rate of blood destruction after administra- 
tion of hemolytic agents, is a third factor to be considered 
in any attempt to explain the lessened tendency in these 
animals to hemoglobinuria and jaundice. 

Anaemia is, of course, no longer operative in animals 
splenectomized for long periods of time in which the blood 
picture has returned to normal. In such the increased 
resistance of the red cells, which persists indefinitely — our 
longest observation covers twenty months — must be a 
factor which cooperates with the mechanical factor pre- 
viously discussed to limit the degree of jaundice. In such 
animals a faint trace of jaundice — never as much as in 
the control animal — is not unusual. 

This persistence of the lessened tendency to jaundice 
one year after splenectomy is shown in the following table : 



78 



THE SPLEEN AND ANEMIA 



TABLE XXIII 

Effect of Hemolytic Serum One Year After Splenectomy, With 

Control 



Time 



Before injec- 
tion 

1st injection 

After injection 
1-3 days 

3 days 
2d injection 

4 days 

5 days 

6 days 



One year after splenectomy 
(dog 42) 



Weight, 6,400 gm. 
Urine : no albumin, no bile 

Received in vein 0.5 c.c. 

serum per kilo. 
Urine: trace of albumin; 

faint trace of bile 

Received in vein 1 c.c. of 

same serum per kilo. 
Marked hemoglobinuria 
Faint hemoglobinuria; 

doubtful bile test 
Faint hasmoglobinuria; 

faint but definite bile 

test 
Died. No evidence of 

jaundice at autopsy 



Time 



Before injec- 
tion 

1st injection 

After injection 

1 day 

2-3 days 

3 days 
2d injection 

4 days 

5 days 

6 days 



Control (dog 43) 



Weight, 6,615 gm. 

Urine: no albumin, no 
bile 

Received same dose of 
same serum as dog 42 

Urine: trace of albumin; 
well marked bile test 

Urine: no bile 

Received same dose of 
same serum as dog 42 

Marked hemoglobinuria 

Moderate hemoglobin- 
uria; marked bile test 

Faint hemoglobinuria; 
large amount of bile 

Urine: no hemoglobin; 
deeply bile-stained 

Chloroformed. At au- 
topsy general bile 
staining of tissues 



We may conclude, therefore, that three factors are 
concerned in the decreased tendency to jaundice when 
hemolytic agents are administered to splenectomized ani- 
mals. The most important is the mechanical factor, the 
disturbance of the spleen — liver circulation; the second, 
always present, is the increased resistance of the red cells. 
These two factors apparently always work together. A 
third possible factor, not always clearly demonstrable, is 
that of anaemia. 



(5) Hemolytic Power of Splenic Extracts 

The histologic evidence of the destruction of erythro- 
cytes by phagocytic cells of the spleen has naturally sug- 
gested the possibility of the liberation by these cells of a 



REGULATORY INFLUENCE OF THE SPLEEX 79 

ferment capable of acting extracellularly. If it could be 
demonstrated that such a free hemolysin is present in the 
spleen we would have at once an adequate explanation of 
the decreased tendency to jaundice in the splenectomized 
animal, for with the spleen absent fewer red cells would be 
destroyed and less haemoglobin sent to the liver for the 
elaboration of bile-pigment. As. this hypothesis has been 
made the basis for splenectomy in hemolytic anaemias, we 
have gone into this question in some detail. The literature 
of the subject shows that during the past few years several 
investigators have tested the influence of such spleen ex- 
tracts upon red cells. The methods employed, based on 
the technique of Korschun and Morgenroth, 225 are very 
similar, but the results obtained have been very contra- 
dictory. Korschun and Morgenroth found in several or- 
gans a hemolytic substance of unknown origin, coctostabile 
and soluble in alcohol, which did not arise from constituents 
of the blood-serum and was in no way peculiar to the spleen. 
Xolf, 317 on the other hand, found that the hemolytic power 
of splenic extract was distinctly greater than that of the 
liver, mesenteric lymph-nodes, or kidneys, but only slightly 
more than that of the lung. This hemolytic substance was 
specific for the species and was destroyed at 100° C. 
Achard, Foix, and Salin, 3 repeating these experiments, 
showed that the final solution was strongly acid, presuma- 
bly as the result of bacterial action, and that control tests 
made with precaution as to asepsis were uniformly nega- 
tive. Widal, Abrami, and Brule, 469 in similar experiments, 
could get no haemolysis with fresh extracts used on the day 
they were prepared; sometimes, also, extracts 24 to 48 
hours old were without effect. From these results they 
conclude that the hemolytic substance is not a true haemo- 



80 THE SPLEEN AND ANEMIA 

lysin, but the product of cell autolysis. Iscovesco and 
Zacchiri 196 have shown that after placing the mixture of 
pulp and saline solution in the thermostat for fifteen to 
twenty hours the filtered extract, on the addition of red 
cells and after standing two and one-half hours in the ther- 
mostat, exhibits 2.5 per cent, to 8 per cent, haemolysis, as 
determined by the Dubosc colorimeter, and conclude that 
the hsemolytic power of splenic extracts is unimportant. 
Weill 464 found a weakly hemolytic substance in extract 
of spleen that was inactivated at 56° and reactivated with 
guinea-pig serum. This was more powerful than a lymph- 
node extract prepared in the same way, but much less 
powerful than the extract obtained from the spleen by long 
maceration. The latter was not destroyed below 80° C, 
and its action was hindered by adding fresh serum. Ex- 
tracts from lymph-nodes prepared in the same way showed 
only slight hsemolytic action, and those from other organs 
were negative. Banti 29 and Furno 134 state that fresh 
extracts of the normal spleen sometimes have no hsemolytic 
action and sometimes a weak action which is increased on 
standing 24 to 48 hours on ice and is not destroyed by 
heating to 60° or even 100°. They consider it a cyto- 
hsemolysin, normally present in the spleen in small amounts 
and much increased after the administration of hsemolytic 
agents. Thus we find that TsTolf, Weill, Banti, and Furno 
find splenic extracts to have a hsemolytic action greater 
than that of other organs. Achard, Foix and Salin, and 
Widal, Abrami and Brule, on the other hand, fail to find 
any hsemolytic action of the fresh extract, and think it 
occurs only after autolysis or bacterial decomposition of 
the spleen. 

Our experiments were made with extracts from the 



REGULATORY INFLUENCE OF THE SPLEEN 81 

spleens of three dogs. The technique described by Xolf 
was followed in the main, with several additions in the way 
of control experiments. On washing through the aorta 
it was found that the technique which will give a blood-free 
kidney or liver will not render the spleen bloodless. Various 
expedients were tried, therefore, to secure a ha?moglobin- 
free extract. It was found that if the spleen, after washing 
through the aorta, was cut in small pieces and pounded 
with a pestle against a wire-meshed sieve placed in a 
mortar, with the aid of frequent washings with salt solu- 
tion, a blood- free white mass was obtained consisting partly 
of reticulum and partly of adherent splenic pulp. (In 
Table XXIV this is called "Extract A.") As it was 
possible that the hemolytic substance might not be re- 
tained, or in only small amounts, in this fraction, extracts 
were also made from that part of the spleen that was 
mashed through the sieve. This residue was, of course, 
distinctly blood tinged, so that it was necessary, in order 
to remove the blood, to mix it with distilled water, centri- 
fuge, discard the supernatant fluid, and repeat the process 
until colorless tissues were obtained. (In Table XXIV 
this is termed " Extract B.") In each case the material 
thus obtained was mixed with double the amount of salt 
solution and placed in the refrigerator. Tests were always 
made with extracts one or two hours old — a small portion 
being filtered off for this purpose — and in two instances 
also after eighteen and twenty-four hours. Control tests 
were made in one experiment with extracts of liver and 
mesenteric lymph-nodes. As it was possible to wash these 
organs free of blood before removal from the body, extracts 
were easily obtained by grinding the tissues in sand with 
mortar and pestle and placing them as before in the ice- 

6 



82 THE SPLEEN AND ANAEMIA 

chest with double the amount of salt solution. In two 
experiments the tests were made on the corpuscles of the 
animal furnishing the spleen; in one the corpuscles of 
another dog was used without a difference in result. The 
preparation of the washed red blood-corpuscles, the dilu- 
tions, incubation, and so forth, were according to Nolf 's 
technique. Each tube contained 0.1 c.c. of washed dog's 
corpuscles with varying amounts of splenic extract made 
up to 2 c.c. with normal salt solution. Controls were made 
with normal salt solution and distilled water. The results 
are presented in Table XXIV. 



TABLE XXIV 
The Hemolytic Power op Extracts op Spleen and Other Organs 



Character of extract 


Amount of splenic extract in c.c. 


Salt 
solu- 
tion 
con- 
trol 


Dis- 
tilled 
water 




1.95 


1.5 


1.0 


0.5 


0.3 


0.2 


0.1 


0.05 


trol 


1. Dog 1. Fresh spleen ex- 

tract A 

2. Dog 2. Fresh spleen ex- 

tract A 

3. Same. Extract B 

4. Same. After extraction in 

ice chest for 24 hours . . 

5. Dog 3. Fresh spleen ex- 

tract A 

6. Spleen extract A after ex- 

traction in ice chest for 
24 hours 

7. Fresh spleen extract (boiled) 

8. Fresh liver extract 

9. Fresh mesenteric lymph 

node extract 

10. Mesenteric lymph node ex- 
tract after extraction in 
ice chest for 24 hours. . . 


V.S. 







V.S. 




V.S. 
















V.S. 























V.S. 



? 










V.S. 




? 









V.S. 
M. 

















V.S. 




































C. 

C. 
C. 

C. 

C. 

C. 
C. 

c. 
c. 

c. 



=no haemolysis; ? =doubtful haemolysis; V.S. =very slight haemolysis; M =marked 
haemolysis; C. =complete haemolysis; — =no test. 

From these observations it would appear that fresh 
extracts of spleen are devoid of definite haemolytic action. 
Occasional irregular results, not to be explained, are found, 
but these occur likewise in the control extracts of liver 



REGULATORY INFLUENCE OF THE SPLEEN 83 

and mesenteric lymph-nodes. Extracts 24 hours old, pre- 
pared at low temperature, show little or no increase in 
hemolytic activity. Boiled splenic tissue, extracted in 
the cold for 24 hours, is inert. 

From these results we are forced to the opinion that 
our present methods of demonstrating haemolysis in vitro 
are not adapted to proving the presence of a hemolysin 
in fresh extracts of the normal spleen, and we are inclined 
to agree with those who believe the reported positive results 
to be due to the products of organ autolysis or bacterial 
action. Moreover, we believe that no accuracy can be 
claimed for work done with extracts which are not free at 
the outset of both red cells and haemoglobin. We do not, 
however, deny that the spleen contains a hemolytic body. 
The histological evidence of the presence in the spleen of 
cells which engulf and destroy red cells, and which pre- 
sumably cause this destruction through a ferment action, 
forbids such an opinion. These cells may contain a haemo- 
lysin which may act, as Banti suggests, intracellularly, 
or, when they are destroyed, extracellularly, but of this we 
have as yet no proof. 

(6) Influence of Fatty Acids and Lipoids in 

Haemolysis 
Another theory of haemolysis is that which involves 
the action of fats and lipoids and with which are associated 
the names of Joannovics and Pick. 201 This is based on 
the fact that larger doses of toluylenediamine are necessary 
to cause icterus in splenectomized dogs than is the case in 
normal animals and also upon the fact that toluylenedia- 
mine is not hemolytic in vitro. It is evident that if toluy- 
lenediamine is hemolytic in vivo and not in vitro some factor 
other than the drug itself is concerned. This cannot be the 



TILE SPLEEN AND AX.EMIA 

spleen alone, for in splenectomized dogs haemolysis can be 
produced, if large enough doses — two to three times the 
usual amount — are used. Joannovies and Pick found that 
in toluylenediamine poisoning they could obtain from the 
liver a hemolysin soluble in ethyl and methyl alcohol and 
in ether and acetone, and resistant to heat. Between acute 
and chronic poisoning were found certain differences. In 
chronic intoxication the hamiolysin was influenced by the 
absence of the spleen, that is. liver extracts from splenecto- 
mized animals were less active. In acute poisoning the 
hemolytic power of the liver extract was not influenced 
by the absence of the spleen. In these livers were found 
palmitic, stearic, and oleic acids. Hemolytic bodies simi- 
lar to those described by Joannovies and Pick have been 
found in human livers in phosphorus poisoning and acute 
yellow atrophy i Jakoby). 199 

Maidorn.-- 5 whose experiments are in general confirma- 
tory of the observations described, finds that the haemo- 
lytic substance occurs only in the presence of fatty de- 
generation. Eppinger : - and King,- 13 on the basis of 
these various observations, studied the fat content of the 
blood of normal and splenectomized animals and of a num- 
ber of individuals suffering from diseases characterized 
by haemolysis, in order to determine whether any of these 
conditions were associated with an increase or decrease in 
the blood, of unsaturated fatty acids. According to their 
results, the blood of the dog after splenectomy shows an 
increase oi the total fats and. as a rule, of cholesterin. 
with a lowering of the iodine figure representing the un- 
saturated fatty acids: the fismres for the cholesterin esters 
were variable. Typical experiments from King's papers 
are presented in Table XXV ( a^ . 

These figures naturally raise the question of the pos- 



REGULATORY INFLUENCE OF THE SPLEEN 



85 



sible influence of cholesterin and the unsaturated fatty 
acids in changing conditions of haemolysis after splenec- 
tomy. The change in fatty acids is especially important, 

TABLE XXV (a) 
Blood Fat of the Dog Before and After Splenectomy (From King 213 ) 



Whole blood 


Total fat* 


Cholesterin* 


Cholesterin 
esters* 


Iodine 
number 


Dog 4 

With spleen 

Without spleen, 14 days. . . 
Without spleen, 2 months. 

Dog 9 

Serum — with spleen 

Serum — without spleen. . . . 
Corpuscles — with spleen. . . 
Corpuscles — without spleen 


6.601 
9.085 
8.328 

4.449 
9.815 
3.883 
6.377 


0.572 
0.617 
0.625 

0.120 
0.318 
0.393 
0.192 


0.306 
0.390 
0.309 

0.132 
0.348 
0.048 
0.262 


110.9 
12.3 
60.1 

101.2 
26.0 
53.8 
53.3 



♦Figures represent grammes per 1000 c.c. of blood. 



TABLE XXV (6) 
Blood Fat of the Dog Before and x\fter Splenectomy (Dubin and Pearce") 





Before 
splenectomy 


Ten days after 
splenectomy 




Dog 


Total* 
fats, gm. 


Iodine* 
number 


Total 

fats, gm. 


Iodine 
number 


Remarks 


15-55 Serum 

Cells 

15-67 Serum 

Cells 

15-76 


2.6 

2.98 

2.851 

2.43 

5.63 

5.25 

5.73 

7.6 


51.6 

43.7 

51.6 

53.4 

47.6 

49 

47.4 

70.1 


2.82f 

2.42 

2.83f 

2.43 

5.99 

5.63 

6.036 

7.71 


51.5 

52 

51.5 

49.4 

47 

48.2 

49.6 

65 


>Blood drawn into oxalate 

!>Blood drawn into oxalate 
Blood drawn into alcohol 


15-75 

16-23 

16-4 


Blood drawn into alcohol 
Blood defibrinated 
Blood defibrinated 



* The iodine number is calculated on the basis of the total amount of fatty extract found 
in 100 c.c. of blood; the total fats are calculated per 1,000 c.c. of blood. 

f As some haemolysis took place while separating the cells from the serum, there may be 
some inaccuracy in the relative values given for cells and serum. 

as Eppinger found that in a variety of clinical conditions 
characterized by excessive haemolysis there occurs an in- 
crease of urobilin in the stools which goes hand in hand with 
an increase in iodine number of the blood, and that after 



86 THE SPLEEN AND ANAEMIA 

splenectomy, urobilin sinks to normal as the iodine num- 
ber lessens. Such observations have obviously a definite 
relation to the increased resistance of the red cells and the 
decreased tendency to j aundice we have found constantly in 
the dog after splenectomy. As a preliminary, therefore, 
to experimentation along this line, we repeated the studies 
of Eppinger and King in so far as they related to the total 
fat and unsaturated fatty acids of the blood before and 
after splenectomy." Our results indicate that splenec- 
tomy has no influence on the blood fat and are therefore 
not in accord with those obtained by Eppinger and King 
(see Table XXV [&]). 

Just how the spleen might influence changes in the 
fat and lipoid content of the blood it is difficult to see, but, 
in view of the experiments of Anitschkow 7 demonstrating 
the deposition of anisotropic fats in large quantities in 
the spleen of the rabbit after feeding cholesterin and egg- 
yolk, it is conceivable that the spleen stores or elaborates 
a lipoid concerned directly or indirectly in hsemolysis, and 
that changes in this function may be a factor in the dimin- 
ished jaundice caused, after splenectomy, by a hemolytic 
agent. This hypothesis is sufficiently attractive to justify, 
in view of the contradictions between our work and that of 
Eppinger and King, a delayed opinion, in the hope that 
further experimentation may throw more light on this 
complex problem. In this connection it is of interest that 
Kolmer and Pearce 223 have shown that splenectomy alone 
has apparently no influence upon the property in normal 
rabbit and dog serum of fixing or absorbing complement 
with various non-specific lipoidal antigens. Such effects 
as were observed were attributable to the effect of the 
anaesthetic and not to the splenectomy. 



CHAPTER IV 

CONCERNING THE SUPPOSED REGULATORY INFLUENCE 

OF THE SPLEEN IN BLOOD DESTRUCTION 

AND REGENERATION 

B. IN RELATION TO ANEMIA: (1) A COMPARISON 
OF THE ARTERIAL AND VENOUS BLOOD OF 
THE SPLEEN. (2) THE INFLUENCE OF SPLENIC 
EXTRACT UPON BLOOD FORMATION. (3) THE 
INFLUENCE OF FEEDING SPLEEN TO SPLENEC- 
TOMIZED ANIMALS. (4) THE REPAIR OF AN 
ARTIFICIALLY PRODUCED ANiEMIA IN SPLE- 
NECTOMIZED ANIMALS. (5) THE INFLUENCE OF 
THE SPLEEN ON IRON METABOLISM. 

Many efforts have been made to show that passage 
through the spleen alters the red cells and renders them 
more susceptible to hemolysis. The results of work along 
these lines are very contradictory, but, as our problems 
demanded a first-hand knowledge of the subject, we have 
made a number of experiments 228 in this field. 

(1) A Comparison of the Arterial and Venous Blood 
of the Spleen 

Much of the early work on this subject is not only 
contradictory, but was done before the development of the 
exact methods of blood examination with which we are 
now familiar. Thus Virchow 455 found fewer red cells in 
the blood of the splenic vein than in that of the artery; 
while Malassez and Picard, 26S and Emilianow 103 report 

87 



88 THE SPLEEN AND ANAEMIA 

the opposite. On the other hand, later investigators, Vul- 
pius 460 and Paton, Gulland and Fowler, 330 have found no 
constant or noteworthy differences. 

Considering the spleen as a possible leucoblastic organ, 
numerous early observers found relatively more leucocytes, 
especially so-called young forms, in the blood emerging 
from the spleen than in that entering it. Tarchanoff and 
Swaen, 427 as also Virchow, 455 could not find any note- 
worthy difference, whereas Paton, Gulland, and Fowler 330 
noted a constant diminution in the number of leucocytes 
in the splenic vein as compared with the general circulation. 
In this connection Bulgak, 62 who describes an increase in 
leucocytes in the splenic vein, states that this is true of the 
venous blood of all parenchymatous organs. Freyer 130 
concludes, from his comparative counts, that the spleen has 
nothing to do with blood formation. 

All this work, of course, refers to mature animals. It 
is generally accepted that in fetal life the spleen has the 
power of extensive blood formation, and several reports are 
at hand to show that in the adult the spleen may undergo, 
in the presence of injury to the bone-marrow, a myeloid 
metaplasia; 96 that is, that it can regain its fetal function 
under pathological conditions. Whether or not the spleen 
may exert this power of blood formation in the adult under 
normal conditions is very doubtful, though to some ob- 
servers it is still an open question. 

On the other hand, although the spleen certainly de- 
stroys red blood-cells (as is evident from the presence in 
it of large cells, phagocytic for erythrocytes, which are 
present in increased numbers under certain pathological 
circumstances) , there is still some doubt as to whether this 
destruction by phagocytosis is the only method of red- cell 



REGULATORY INFLUENCE OF THE SPLEEN 89 

disintegration. Many investigators claim that the erythro- 
cytes, in their passage through the spleen, are so acted upon 
by some unknown substance as to become more susceptible 
to haemolysis. 

This is the basis of Bottazzi's 53 haemocatatonistic theory, 
which has recently received support from Banti 29 and his 
colleague, Furno. 134 In the course of an investigation of 
haemolytic splenomegaly, they studied normal animals and 
those receiving hemolytic serum and came to the con- 
clusion that free haemoglobin can be demonstrated in the 
blood of the splenic vein both in normal animals and in 
those receiving haemolytic serum. Sometimes they found 
it in the blood of other vessels, but always in less amounts 
than in the splenic vein. These findings they consider 
as evidence of haemolysis in the spleen. Also the red 
blood-cells of the splenic vein were found to be less resistant 
to hypotonic salt solution than were those of the general 
circulation. On the other hand, investigations by Chalier 
and Charlet 71 on the resistance of red cells in the splenic 
artery and vein gave very different results. Although 
they found that venous blood in general was slightly less 
resistant than arterial blood, in the splenic system this 
was reversed, so that the blood of the splenic vein was 
more resistant than that of the splenic artery and much 
more so than the blood of other veins. Hammarsten also, 
according to Gabbi, 185 found that the splenic vein blood 
was more resistant than the arterial. 

In the observations of Banti and Furno, the reference 
is to free haemoglobin in the serum and not to the increased 
haemoglobin content of venous or splenic blood described 
by several investigators. This claim is most surprising, in 
that they state that the dissociated haemoglobin of the 



90 THE SPLEEN AND ANAEMIA 

serum (" emoglobin diseiolta dal siero ") is not only always 
present in the splenic vein of normal animals, but some- 
times in sufficient quantities to be measured by a Sahli 
haemoglobinometer. It is to these observations that we 
have given especial attention in our work. 

Methods. — From dogs under ether anaesthesia blood 
was obtained directly as it flowed from the splenic artery 
and the splenic vein. Great care was exercised to disturb 
the vessels and the organs as little as possible, as it has 
been shown by Grigorescu 155 and Pribram 361 that the cell 
content of the blood may be greatly increased by conges- 
tion of the spleen. From a nick in the wall of one of the 
branches of the artery or vein fresh blood was drawn 
directly into Thoma blood-counting pipettes and the capil- 
lary tube of a v. Fleischl haemoglobinometer. From an- 
other branch blood was withdrawn by a syringe and imme- 
diately distributed to tubes containing different strengths 
of hypotonic salt solution designed to test the resistance 
of the red cells. Some of the blood was also set aside for 
similar tests with washed cells. For the determination of 
the presence of free haemoglobin in the serum blood was 
collected in three ways: (1) in a paraffined centrifuge 
tube, (2) in a tube containing potassium oxalate, and (3) 
by drawing it directly into tubes through capillary points, 
which were then sealed. All three samples were centri- 
fuged and the serum examined for haemoglobin by visual 
inspection and the spectroscope. Smears for differential 
counts were made at times from the blood flowing directly 
from the vessel, and at times from a drop from the syringe. 
Finally, tests for reticulated or skeined (young) red blood- 
cells were made. This was done by letting a few drops of 
blood fall into a solution of brilliant cresyl blue, and, after 



REGULATORY INFLUENCE OF THE SPLEEN 91 

standing fifteen or twenty minutes, the skeined forms in 
proportion to the unskeined or mature forms were counted 
in fresh smears. For the purpose of controls, blood from 
the femoral vein and from the capillary circulation (by 
puncture of the skin) was occasionally collected. 

Results. — The figures 228 for the red and white cells, 
differential counts, and total haemoglobin in a series of 
five dogs show that, so far as these estimations are con- 
cerned, the blood of the splenic vein does not differ greatly 
from that of the artery. The variations are not uniformly 
on one side, and are all within the limit of error inherent 
in the methods of blood examination.* 

It is of interest that in six of eight animals the red cells 
of the vein showed more or less marked anisocytosis and 

* Since these observations were made, Morris 301 has published 
similar studies on the cat. He comes to the conclusion that the spleen 
plays a definite role in the formation of the red blood-cells. This 
conclusion is based on the counting of the red cells in the splenic 
artery and vein, the number in the latter being one to four million 
greater than in the artery; in one animal, for example, 4,400,000 per 
c.mm. in the artery as against 9*120,000 in the vein. Morris's technic 
appears to differ from ours only in that he collected his blood from the 
stagnant stream between two clamps, while we took the free-flowing 
blood as it passed out of a small nick in the vessel wall. Comparative 
tests which we have made, since his publication, of stagnant and flow- 
ing splenic vein blood show that sometimes in the former the count 
may be one to three million higher than in the latter ; in other instances, 
it is the same. We are therefore inclined to think that Morris's high 
counts may be due to mechanical causes, especially as in repetitions 
of, our earlier work, three dogs being used, we found a variation 
between the artery and vein of never more than 500,000 cells. The 
higher count occurred twice in the venous blood and once in the arterial 
blood — variations well within the limit of error of blood-counting 
methods. 



92 THE SPLEEN AND ANEMIA 

inequality of staining, which were not seen to the same 
degree in the blood of the artery. Polychromatophilia was 
about equal in blood of the artery and the vein. In two 
of the eight experiments a few normoblasts were found in 
the splenic vein blood only. Control smears from the 
femoral vein of four dogs showed changes in the red cells 
about equal to that of the splenic vein, indicating that these 
changes are characteristic of venous blood in general rather 
than any specific change caused by passage through the 
spleen. 

In regard to the presence of free haemoglobin in the 
serum, if we had depended on one tube only we would 
have occasionally found apparent haemoglobinsemia, both 
in the general circulation and in the splenic vein; but as 
in every set of three tubes, in a series of seven dogs, at 
least one was free of haemoglobin, we cannot support the 
view that free haemoglobin in demonstrable amounts is 
present normally either in the splenic vein or the general 
circulation of the dog. Our experience forces us to the 
conclusion that the findings of other investigators are due 
to haemolysis after collection or are dependent upon the 
method of separating the serum.* 

As regards the resistance of the red cells of the vein 

* During the past few years, in connection with investigations on 
coagulation of blood, Abderhalden's theory of protective enzymes, 
Folin's microchemical methods, and the phenomena of anaphylaxis, 
much time and attention has been given in this laboratory to the collec- 
tion of plasma and serum from the dog and rabbit. In our experience 
careful collection always yields these fluids free of haemoglobin; dis- 
colored sera we have always regarded as due to errors in the method 
of collection. With our experience in mind, we cannot support the 
statements of Banti and Furno that free haemoglobin, in amounts 
sufficient to be recognized, occurs normally in the serum. 



REGULATORY INFLUENCE OF THE SPLEEN 93 

as compared with the artery, tests were made on eight 
dogs: in five no difference was found; in the other three 
the venous corpuscles were slightly less resistant. Two 
control tests with cells from the femoral vein showed these 
to have the same resistance as cells of the splenic vein hlood. 
The question arises, therefore, as to whether the differ- 
ences described heretofore are not those of arterial and 
venous blood in general. 

In seven comparative tests for skeined or reticulated 
red corpuscles these were found to be more abundant in 
five in the splenic vein and in two in the artery ; the differ- 
ences were never very striking. Five controls from the 
femoral vein corresponded more closely to the splenic 
artery counts than to those from the splenic vein. 

As a result of these various observations we conclude 
that the slight differences between the arterial and venous 
blood of the spleen are within the limits of error inherent 
in the methods of blood examination, and are not to be 
explained by a peculiar action of the spleen. In some 
instances peculiarities shown by the splenic venous blood 
are common to the venous blood of the general circulation. 
Banti and Furno's observation concerning the presence 
of free haemoglobin in the blood of the splenic vein is 
not confirmed. 

2. Influence of Splenic Extract Upon Blood 
Formation 
Nearly all investigators grant the spleen a function in 
the destruction of red cells; and some ascribe to it a part 
in red-cell formation. This latter view is based largely 
on the fact that in fetal life red cells are formed in the 
spleen, and that under pathological conditions myeloid 



94 THE SPLEEN AND ANAEMIA 

metaplasia may occur. We have, however, no satisfactory 
evidence that this function is continued under normal con- 
ditions beyond a short period after birth. Some work has 
been done with splenic extracts, as by D anile wsky, 87 to 
show that the spleen contains a substance which stimulates 
the formation of red cells in the bone-marrow. Danilewsky 
found a surprising increase in haemoglobin and red blood- 
cells after a single subcutaneous or intraperitoneal injection 
of extracts of spleen. This increase reached its height in 
from three to seven days and continued as long as the ex- 
periment lasted, usually eight days. In dogs with a dietary 
anaemia,* splenic extract caused an even greater rise; for 
example, of 40 per cent, haemoglobin and almost 2,000,000 
red cells. This influence of the splenic extract was not 
destroyed by heating. Danilewsky assumed that his re- 
sults were due to a stimulation of the bone-marrow. As 
Danilewsky's work is uncontrolled by injection of other 
organ extracts, we have repeated his experiments. Silves- 
tri 408 records a single observation in which a dog, pre- 
sumably dying from anaemia, was apparently saved by 
the injection of splenic extract. In this connection it must 
also be noted that the clinical literature of this subject con- 
tains several reports of the use of extracts of spleen and 
bone-marrow with good results in the treatment of anaemia. 

Method. — We have tested the effect of splenic extract 
on four dogs, using as controls extracts of other organs 
similarly prepared and extracts of erythrocytes. 

The usual examinations of the blood were made, as 
were also determinations of the resistance of the erythro- 
cytes to hypotonic salt solution and of the percentage of 

* Anaemia due to a diet of rice only ; red cells fell to 3,980,000. 



REGULATORY INFLUENCE OF THE SPLEEN 95 

skeined cells. As a rule, two counts were made before 
injection and daily counts after the injection until the 
blood picture had returned to normal, usually a period of 
from three to four days. Extracts were prepared from 
organs removed aseptically from dogs bled to death under 
ether anaesthesia. The finely chopped organ was ground 
in a sterile mortar to a homogeneous pulp and extracted 
with double the volume of salt solution for two hours in 
the ice-chest. Ten cubic centimetres of the filtered extract 
was injected intraperitoneally into dogs of about the same 
weight. As the splenic extract contained a considerable 
amount of blood, it was necessary to use as control defib- 
rinated blood (10 c.c), diluted with normal salt solution 
(1 to 20), in order to determine the possibility of the rise 
in red cell count being due to the influence of some con- 
stituent of the red cells. In no case did peritonitis or other 
infection result from the injection. 

The result 22S in one of these experiments is shown in 
Table XXVI. 

TABLE XXVI 
Effect on the Blood Picture of Injections of Splenic Extract 



Date 


Haemoglobin 


Red blood cells 


(1914) 






Feb. 6 


102 


5,250,000 


Feb. 7 


101 
(10 c.c. splenic extract No. 16 injected) 


5,650,000 


Feb. 8 


110 
(15 c.c. of same extract injected) 


6,500,000 


Feb. 9 


110 


7,040,000 


Feb. 10 


105 


6,800,000 


Feb. 11 


96 


5,330,000 


Feb. 12 


95 
(15 c.c. splenic extract No. 88 injected) 


5,290,000 


Feb. 13 


101 

(10 c.c. of same extract injected) 


5,700,000 


Feb. 14 


104 


6,880,000 


Feb. 15 


98 


5,860,000 


Feb. 16 


96 


5,120,000 


Feb. 19 


106 


5,540,000 



96 THE SPLEEN AND ANAEMIA 

This experiment shows that intraperitoneal injection 
of splenic extract causes a sharp rise in haemoglobin and 
red cell count, lasting only one or two days. This rise 
is repeated on reinjection of either the same or another 
splenic extract. 

In each of three other experiments with splenic extract 
an increase in the number of red cells was obtained, but 
this increase was not always as marked as in the experiment 
presented; it was nevertheless always greater than that 
caused by the use of control extracts of liver, kidneys, or 
blood. 

The study of the resistance of the red cells in these 
experiments may be dismissed with the statement that no 
noteworthy differences were found after injection of any 
extract. The skeined cells also showed no constant change. 
We had hoped that, as the latter are supposed to be young 
forms of erythrocytes, they would be found to be increased 
after the injection of splenic extract had caused a rise in 
the red cell count. Only once, however, in which instance 
the percentage rose from 0.5 to 2, was this noticed. On 
the other hand, in two experiments they were not found at 
all in the blood after injection. 

Intraperitoneal injection of splenic extract is usually 
followed by an increase in the total number of leucocytes, 
consisting chiefly of the polymorphonuclear forms. A 
similar rise occurred in one of three experiments with liver 
and kidney, and in one of two with defibrinated blood. 
Several grades of " transitional cells " appeared in in- 
creased numbers. Eosinophiles were present in increased 
numbers in two of the four dogs receiving splenic extracts, 
but were also definitely increased in two of the five con- 
trols receiving other organ extracts. 



REGULATORY INFLUENCE OF THE SPLEEN 97 

It would appear, therefore, that the intraperitoneal 
injection of saline extracts of fresh spleen constantly causes 
a sharp increase in red-cell count and haemoglobin content. 
The rise is evanescent, lasting but one or two days, and 
may be followed by an equally evanescent drop below 
normal. Similarly prepared extracts from other organs 
fail to give this rise. No noteworthy change is found in 
the resistance of the red blood-cells to hypotonic salt solu- 
tions or in the number of skeined or reticulated erythro- 
cytes after the injections of the various organ extracts. 

A temporary increase of polymorphonuclear and tran- 
sitional leucocytes usually follows the use of spleen ex- 
tract, but may occur also, but less frequently, after the 
injection of liver and kidney. 

The constant increase of red cells in the peripheral 
circulation after injection of spleen, in view of the ten- 
dency to anaemia following splenectomy, suggests that the 
spleen normally may exert a stimulating effect upon the 
formation of red cells in the bone-marrow. 

3. Influence of Feeding Spleen to Splenectomized 

Dogs 
This study complements that just described in that 
spleen in large amounts was fed to splenectomized ani- 
mals. The object was to determine whether through the 
influence of some necessary substance in the spleen the 
anaemia following splenectomy might be prevented. The 
procedure is, of course, analogous to thyroid feeding in 
insufficiency of the thyroid gland, and has an advantage 
over the injection of extracts in that it may be continued 
over long periods of time without the possibility of the com- 
plications occasionally occurring after injection. These 



98 THE SPLEEN AND ANAEMIA 

experiments, it was hoped, would show whether or not the 
spleen exerts some effect upon the hemopoietic system 
through peculiar bodies analogous, perhaps, to those of 
an internal secretion. Thus if the anaemia following sple- 
nectomy depends upon the absence of a stimulus, fur- 
nished normally by the spleen, to the hemopoietic system 
in general, or to some part of it, as the bone-marrow, the 
feeding of normal fresh spleen unmodified by heat or 
chemicals might supply this stimulus and there would then 
be no anaemia after the removal of the spleen. 

Method. — Five dogs were used. Four of these were 
given a diet consisting of raw hashed beef spleen, lard, 
and cracker-meal in amounts estimated, according to the 
weight of each animal, to suit its caloric needs. Of these, 
three were splenectomized and one served as a control. As 
an added control, a splenectomized dog received a diet in 
which casein was substituted for beef spleen. The red 
cells and the haemoglobin were estimated several times 
before splenectomy and afterwards counted twice a week 
for three weeks and then once a week for five weeks. No 
preliminary counts were made until a dog had been on 
the special diet for at least a week, and splenectomy was 
not performed until two weeks later. 

Results. — Of the three splenectomized dogs receiving 
spleen 228 in the diet, one showed only a very slight de- 
crease in red cells and haemoglobin, but the other two de- 
veloped the usual anaemia of splenectomy. Thus one with 
an initial red-cell count of 6,200,000 showed on the twelfth 
day 4,710,000 red cells, with return on the fifty- fourth 
day to 6,040,000. This animal received daily 150 grammes 
of beef spleen. The other dog receiving daily 275 grammes 
of spleen showed a change in red-cell content of about the 



REGULATORY INFLUENCE OF THE SPLEEN 99 

same degree. In the spleneetomized dog not fed spleen the 
red cells fell from 5,500,000 to 4,210,000 on the 19th day, 
with return to 5,060,000 on the fifty-fourth day. In this 
dog the haemoglobin reached its lowest level ( 65 per cent. ) 
on the twelfth day, and remained at about that point until 
the twenty-sixth day. In none of the other spleneetomized 
dogs receiving spleen did the hsemoglohin fall below 75 
per cent. The normal dog, receiving 150 grammes of 
spleen daily, showed no change in the blood. 

It is evident that in two dogs, despite the feeding of 
spleen, an anaemia was produced that ran a course very 
similar to that which we have previously shown to be the 
rule in spleneetomized dogs. In view of these very definite 
results, the mildness of the anaemia in the third spleneeto- 
mized dog cannot be considered as a sparing influence due 
to the feeding of spleen tissue.* 

* The observation has recently been made by Lewis and Margot 24T 
that the feeding of fresh sheep spleen to spleneetomized animals gives 
rise to an acute intoxication that is sometimes fatal. This was fre- 
quently observed in spleneetomized mice., and was noted in one of two 
spleneetomized dogs. As an intoxication such as Lewis and Margot 
describe might be a disturbing factor in the study of anaemia, we have 
repeated our feeding experiments with beef spleen and have watched 
with special vigilance for the appearance of symptoms of intoxication. 
One dog was given a diet of raw beef spleen, lard, and cracker-dust 
for two weeks after splenectomy, and, as no untoward symptoms had 
developed in that time, pure beef spleen alone was given daily for three 
days. This he ate with relish, devouring over 1200 grammes of spleen 
during these three days, but at no time showed any signs of anorexia, 
nausea, vomiting, chills, or in fact any untoward symptoms whatsoever. 
Another dog was fed beef spleen, lard, and cracker-dust for ten days 
before and for two weeks after splenectomy. Neither this animal nor 
the normal control on the same diet showed any of the symptoms 
described as occurring after the feeding of sheep's spleen. The mod- 



100 THE SPLEEN AND ANEMIA 

As, therefore, the feeding of fresh raw spleen to sple- 
nectomized dogs has no clearly defined influence in pre- 
venting the anaemia which usually occurs after splenec- 
tomy, a regulatory influence of the spleen, in this regard 
at least, cannot be assumed. 

4. The Repair of an Artificially Produced Anemia 
in Splenectomized Animals 

In the hope of throwing some light upon the problem 
of the regeneration of the blood in the absence of the spleen 
we have allowed animals to recover from the anaemia fol- 
lowing splenectomy and have then caused anaemia in vari- 
ous ways and followed for long periods of time the changes 
in the blood picture. 227 These studies have brought out 
the interesting fact that, despite the increased resistance 
of the red cells and the lessened tendency to jaundice, 
the ansemia caused in splenectomized animals by hemolytic 
agents may be of greater severity, as shown by direct blood 
examination, and always runs a longer course and has a 
longer period of repair than in the case of the normal dog. 
We have, therefore, the apparent paradox that an animal 
with more resistant corpuscles suffers a severer and more 
prolonged, although more slowly developing, anaemia than 
with corpuscles of the normal resistance. Before further 
discussing this apparent paradox, our methods and the 
results of detailed experiments may be presented. 

Methods. — The animals were given a simple but 

erate anaemia which developed in the two splenectomized animals fol- 
lowed the course usually observed in splenectomized dogs. Considering, 
also, the three dogs previously studied by us, we therefore conclude 
that the phenomena observed by Lewis and Margot after feeding 
sheep's spleen do not occur in splenectomized dogs fed with beef spleen. 



REGULATORY INFLUENCE OF THE SPLEEN 101 

abundant diet, practically uniform in character and con- 
taining roughly the same constant amount of iron-yielding 
material. The iron in the diet was not, however, in this 
series of experiments, estimated quantitatively. After 
preliminary blood examinations had been made the spleen 
was removed aseptically, by a practically bloodless opera- 
tion, under ether anaesthesia. The' blood examinations 
were then continued, at first at short intervals and later 
at longer intervals. At various stages of the process of 
blood regeneration haemolytic immune serum or sodium 
oleate was administered, with, at the same time, the ad- 
ministration of an equivalent amount of the hemolytic 
agent to a normal animal serving as control. For the 
purpose of further control, animals were rendered anaemic 
by bleeding, in order that the regeneration of the blood 
in this type of anaemia might be contrasted with that due 
to haemolytic agents. The examination of the blood was 
continued after the production of anaemia, the intervals 
between examinations being gradually lengthened, and 
included the estimation of red cells, haemoglobin content, 
and the white cells, with differential counts of the latter 
and the determination of the resistance of the red cells to 
various percentages of hypotonic salt solution. 

The two experiments given in detail in Tables XXVII 
and XXVIII represent the longest periods that animals 
have been observed after the administration of haemolytic 
serum. In all other experiments of this group, although 
the animals were carried for shorter periods, the general 
course of the anaemia was the same. The two tables are 
deemed sufficient, therefore, to illustrate the onset and 
repair in this type of anaemia. The first experiment 
(Table XXVII) is of interest chiefly in connection with 



102 



THE SPLEEN AND ANAEMIA 



the question of the length of time necessary, in the sple- 
nectomized as compared with the normal dog, for a com- 
plete regeneration of the blood to occur after the destruc- 
tion caused by hemolytic serum. It will be seen that in 

TABLE XXVII 

Effect of Hemolytic Serum on Blood Picture of Splenectomized Dog 

and Control * 







Hsemolytic Immune Serum 61 






Dog 51. Weight 8,120 gm. (26 days after sple- 


Dog 53. Weight 7,780 gm. 0.25 c.c. haemolytic 


nectomy.) 0.2c. c 


. hsemoly tic serumper kilo . in vein 


serum per kilo, injected 




Haemoglobin, 
per cent. 


Red blood cells 




Haemoglobin, 
per cent. 


Red blood cells 


Before 


90 


5,230,000 


Before 


92 


6,200,000 


23^ hours 


72 


3,800,000 


3 hours 


78 


4,970,000 


1 day 


60 


3,510,000 


1 day 


38 


2,060,000 


3 days 


66 


3,920,000 


2 days 


30 


2,250,000 


6 days 


54 


2,730,000 


4 days 


38 


3,100,000 


8 days 


38 


2,310,000 


6 days 


49 


3,420,000 


10 days 


55 


3,100,000 


8 days 


42 


3,400,000 


14 days 


48 


2,870,000 


10 days 


42 


3,110,000 


17 days 


53 


3,220,000 


12 days 


50 


3,980,000 


22 days 


51 


3,060,000 


17 days 


64 


3,810,000 


28 days 


67 


3,510,000 


24 days 


80 


4,230,000 


34 days 


64 


3,390,000 


31 days 


86 


4,530,000 


44 days 


76 


4,880,000 


66 days 


81 


5,120,000 


56 days 


85 


4,210,000 


86 days 


92 


5,380,000 


70 days 


63 


3,540,000 


107 days 


105 


6,510,000 


79 days 


79 


4,120,000 








100 days 


86 


4,010,000 








136 days 


82 


4,200,000 








200 days 


110 


6,200,000 









* The period intervening after splenectomy is indicated in parentheses after the number 
of the animal. The word "before" in the time column refers to the blood count made a short 
time before the injection of the hsemolytic agent and not to the blood count before splenectomy. 
Likewise hours and days in the same column are indicative of the length of time after such 
injection. 

the normal dog the lowest figures were those of the second 
day, and that an approach to normal figures was evident 
after two months, but that the latter was not actually 
reached in the case of haemoglobin until the third month 
and of the red cells until 107 days; on the other hand, the 
splenectomized animal exhibiting a more gradual fall did 



REGULATORY INFLUENCE OF THE SPLEEN 103 



TABLE XXVIII 

Recovery From Injection op Hemolytic Serum of Splenectomized 

and Control 



Doo 



Time 



July 24, 1912 
May 21, 1913 



1st injection 



24 hrs. later 



2d injection 
24 hrs. later 



2d day.. 

3d day . 

4th day 

5th day 
7th day 



Ten months splenectomy, dog 59 



Splenectomy 
Weight 10,900 gm. 
Blood: red cells 5,200,000; 

haemoglobin 86 per cent. 
Fragility: 0.3 +, 0.45- 
Urine: no bile-pigment; 

trace of albumin; no casts 
0.2 c.c. haemolytic serum 

per kilo. 



Blood: red cells 4,820,000; 

haemoglobin 90 per cent. ; 

serum free of haemoglobin 
Fragility: 0.35 +, 0.6- 
Urine: trace of albumin; 

trace of bile-pigment 



Same dose of same serum 

repeated 
Blood: red cells 5,620,000; 

haemoglobin 95 per cent. 
Urine : no haemoglobin ; 

faint but definite trace of 

bile-pigment; trace of 

albumin 
Blood: red cells 4,030,000; 

haemoglobin 75 per cent. 
Urine: bile-pigment abun- 
dant but less than in 

dog 54 
Blood: red cells 3,950,000; 

haemoglobin 56 per cent. 
Urine: good bile reaction, 

but less than in dog 54 
Blood: red cells 3,580,000; 

haemoglobin 52 per cent. 
Urine : trace of bile 

Blood: red cells 3,550,000; 

haemoglobin 57 per cent. 
Urine: bile reaction slight 
Blood: red cells 3,660,000; 

haemoglobin 52 per cent. 
Urine : no albumin or bile 



Time 



May 21, 1913 



1st injection 



24 hrs. later 



2d injection 
24 hrs. later 



2d day. 



3d day. . . . 

4th day . . . 

5th day . . . 
7th day... 



Control, dog 54 



Weight 12,800 gm. 
Blood: red cells 5,400,000 
haemoglobin 104 percent. 
Fragility: 0.3 -f, 0.5- 
Urine: not obtained. 

0.2 c.c. per kilo, of same 
serum 

Urine shows faint trace of 
bile after 10 min. 

Blood: red cells 5,050,000; 
haemoglobin 94 per cent. ; 
serumfreeof haemoglobin 

Fragility: 0.35 +, 0.6- 

Urine: trace of albumin; 
moderate amount of bile- 
pigment present 

Same dose of same serum 

T*pT")fiQ ■fori 

Blood: red cells 4,880,000; 

haemoglobin 98 per cent. 
Urine : slight haemoglobin- 

uria; large amounts of 

bile-pigment 

Blood : red cells 4,480,000; 
haemoglobin 97 per cent. 
Urine : no haemoglobin 

but large amount of 

bile-pigment 
Blood: red cells 4,820,000; 

haemoglobin 95 per cent. 
Urine : bile very abundant 

Blood: red cells 4,460,000; 

haemoglobin 66 per cent. 
Urine : bile decreasing, 

but well marked 
Blood: red cells 4,720,000; 

haemoglobin 74 per cent. 
Urine: abundant bile 
Blood: red cells 5,500,000; 

haemoglobin 86 per cent. 
Urine: moderate bile; no 

albumin 



104 



THE SPLEEN AND ANAEMIA 



TABLE XXVIII— Continued 



Time 



11th day. 

14th day. 
17th day. 

20th day. 

24th day. 

27th day 
31st day. . 

36th day. . 

40th day. . 
46th day. . 



Ten months splenectomy, dog 59 



Weight: 10,040 gm. 
Blood: red cells 4,250,000; 

haemoglobin 54 per cent. ; 

leucocytes 10,400 
Urine: no albumin or bile 
Blood: red cells 4,570,000; 

haemoglobin 72 per cent.; 

leucocytes 14,200 
Urine: faint trace of bile 
Blood: red cells 5,050,000; 

haemoglobin 86 per cent.; 

leucocytes 16,000 
Urine: no albumin or bile 

Weight 10,415 gm. 
Blood: red cells 4,780,000; 

haemoglobin 79 per cent.; 

leucocytes 14,400 
Blood: red cells 5,440,000; 

haemoglobin 92 per cent. 
Urine: no albumin or bile 
Blood: red cells 5,020,000; 

haemoglobin 90 per cent. 
Blood: red cells 3,480,000; 

haemoglobin 70 per cent. ; 

leucocytes 13,400 
Fragility: 0.275 +, 0.55- 
Blood: red cells 4,870,000; 

haemoglobin 98 per cent. 
Urine: no albumin or bile 
Blood: red cells 5,970,000; 

haemoglobin 102 per cent. 
Weight 10,820 gm. 
Blood: red cells 5,140,000; 

haemoglobin 98 per cent. 
Fragility: 0.35 -h 0.45- 



Time 



11th day.. 

14th day. 
17th day.. 

20th day, 
24th day. 

33d day. . 



46th day. 



Control, dog 54 



Weight 11,980 gm. 
Blood: red cells 5,800,000; 

haemoglobin 84 per cent. ; 

leucocytes 17,000. 
Urine: no bile 
Blood: red cells 5,640,000; 

haemoglobin 102 per 

cent.; leucocytes 18,200 
Urine: faint trace of bile 
Blood: red cells 6,100,000; 

haemoglobin 106 per 

cent. 
Urine: no albumin; very 

faint trace of bile 
Weight 12,365 gm. 
Blood: red cells 6,080,000; 

haemoglobin 109 per 

cent.; leucocytes 20,700 
Blood: red cells 6,120,000; 

haemoglobin 110 per 

cent.; leucocytes 13,200 



Blood : red cells 6,200,000; 
haemoglobin 110 per 
cent.; leucocytes 13,200 

Fragility: 0.325 +,0.55- 



Weight 12,450 gm. 
Blood: red cells 6,060,000; 
haemoglobin 106 per cent. 
Fragility : 0.35 +, 0.55 - 



not reach its lowest figures until the eighth day, and still 
had a low haemoglobin content and red-cell count at the 
end of 136 days. On account of the long intervals elapsing 
in each case before the final count, the exact dates of 
return to normal cannot be given, but it is clear that one 
month after the control animal had reached its normal red- 
cell count the blood of the splenectomized animal was far 
from its normal state. At the end of 200 days, however, 



REGULATORY INFLUENCE OF THE SPLEEN 105 

the blood picture of this animal gave higher figures than 
before injection. 

As these animals were of practically the same weight, 
and as the splenectomized dog received less serum than the 
normal dog, it is impossible to escape the conclusion that 
the absence of the spleen is an important factor in the 
chronicity of the anaemia and the slow repair. 

In the second experiment (Table XXVIII) the same 
relative difference in the severity of the anaemia and the 
rate of recovery is seen, but in neither animal was the 
period of recovery as long as in the animals of the first 
experiment. 

Some objection might be raised against the results in 
the first experiment, as this animal, despite the high initial 
count, had been splenectomized only twenty-six days, and 
the resulting slow repair might be due to a combination 
of a slow anaemia secondary to absence of the spleen and 
of the anaemia due to the hemolytic serum. This possible 
objection is removed by the results in the second experi- 
ment, in which the blood of an animal splenectomized 
nearly a year before had returned to normal before injec- 
tion. The theory that the absence of the spleen is respon- 
sible for the slow blood regeneration is thus strengthened. 

Sodium Oleate Ancemia in the Splenectomized Animal 

On account of the advisability of determining the effect 
of another type of haemolytic poison, experiments were 
made with sodium oleate (see Table XXIX). This sub- 
stance, unlike haemolytic serum, produces, as a rule, a tran- 
sient anaemia, quickly repaired in the normal dog. 

Here, also, it is seen that the anaemia was more severe 
and the repair slower in the splenectomized than in the 



106 



THE SPLEEN AND ANAEMIA 



normal animal. In the first experiment the splenectomized 
dog's haemoglobin fell eventually on the thirtieth day to 
54 per cent, and the red cells to 3,700,000, and it took 
forty-three days for the return to normal, whereas in the 
control receiving an equivalent amount of oleate the haemo- 
globin fell on the third day to only 93 per cent, and the 

TABLE XXIX* 
Repair of Sodium Oleate Anemia After Splenectomy, With Control 



Dog 24. 


Weight 9,650 gm. (5 months after 
splenectomy) 


Dog 55. Weight 7,860 gm. Normal 


100 c.c. of 1 per cent. 


sodium oleate in vein 


100 c.c. of 1 per cent, sodium oleate in vein 




Haemo- 
globin 


Red blood 


Leucocytes 




HEemo- 
globin 


Red blood 


Leucocytes 




per cent. 








per cent. 






Before 


89 


5,650,000 


10,600 


Before 


108 


6,460,000 


8.600 


1 day 


68 


3,770,000 


15,600 


3 days 


93 


5,420,000 


7,100 


3 days 


70 


2,320,000 


10,400 


7 days 


112 


6,120,000 


6,400 


7 days 


74 


3,100,000 


10,800 


16 days 


116 


7,240,000 


10,800 


11 days 


70 


4,200,000 


8,600 


24 days 


114 


7,410,000 


8,200 


16 days 


66 


3,420,000 


9,800 










19 days 


66 


3,760,000 


10,200 










24 days 


63 


3,600,000 


10,000 










30 days 


54 


3,700,000 


7,600 










35 days 


63 


3,890,000 


10,000 










39 days 


66 


4,180,000 


9,300 










44 days 


76 


4,220,000 


12,800 










51 days 


79 


4,400,000 


13,600 










57 days 


86 


4,820,000 


8,900 










73 days 


90 


5,780,000 


12,600 










200 days 


110 


6,048,000 













♦The data in this table are arranged in the same manner as in Table XXVII. 



erythrocytes to only 5,420,000, and the return to normal 
occurred four days later. In a second experiment the 
same general results were obtained, but in less striking 
form. In this type of anaemia it is therefore also evident 
that absence of the spleen delays the regeneration of the 
blood; that is, interferes presumably with the normal re- 
action of the bone-marrow. 



REGULATORY INFLUENCE OF THE SPLEEN 107 

Repair of Blood in the S plenectomized Dog After 

Hemorrhage 

A third method of study was to produce ansemia by 

hemorrhage and to observe the rapidity of repair in the 

splenectomized as contrasted with the normal animal (see 

Table XXX). 

TABLE XXX* 

Repair After Hemorrhagic Anemia in a Splenectomized Animal, with 

Control 



Dog 42. Weight 8,020 gm 


. (85 days after splenectomy) 


Dog 55. Weight 7,800 gm 


Normal 


100 c.c. of blood taken from a vein 


150 c.c. of blood taken from a vein 




Haemo- 
globin 
per cent. 


Red blood cells 


Leucocytes 


Haemo- 
globin 
per cent. 


Red blood cells 


Leucocytes 


Before 

1 day 

4 days 

8 days 

12 days 

18 days 

26 days 

34 days 

40 days 

46 days 

54 days 

61 days 

67 days 


92 
78 
68 
76 
85 
84 
70 
74 
90 
93 
95 
90 
102 


5,160,000 
4,570,000 
4,310,000 
3,820,000 
4,380,000 
4,210,000 
4,850,000 
4,100,000 
4,480,000 
4,390,000 
4,760,000 
4,850,000 
5,100,000 


22,400 
26,200 
24,100 
22,100 
16,800 
16,100 
17,400 
12,600 
10,200 
16,400 
13,100 
14,900 
19,200 


95 

78 

78 

105 

108 


5,200,000 
5,100,000 
4,900,000 
6,120,000 

6,460,000 


10,200 

8,300 

10,500 

10,400 

8,600 



* The data in this table are arranged in the same manner as in Table XXVII 

Here it is seen that a small loss of blood causes a 
markedly chronic ansemia in the splenectomized dog, and 
that repair is greatly delayed. After a loss of 100 c.c. 
of blood the haemoglobin of the splenectomized dog was 
lowered on the fourth day to 68 per cent, and the erythro- 
cytes to 4,310,000, with a return to normal sixty-three 
days later. From the control dog of slightly less weight, 
150 c.c. of blood were taken, the haemoglobin dropping to 
78 per cent, and the red cells to 4,900,000 on the fourth 
day and promptly returning to normal by the eighth day. 



108 



THE SPLEEN AND ANEMIA 



Although we have not been especially interested in the 
changes in the white cells, these have been followed in some 
instances. In Table XXXI, which follows, the leukocytic 
counts of the animals presented in Table XXVII are 
shown. 

TABLE XXXI * 
Leucocyte and Differential Counts After Hemolytic Serum 



Dog 51 


. (26 days after splenectomy) 


Dog 53. 


Normal 








Poly- 










Poly- 








Leucocytes 


mor- 

phonu- 

clear 


Small 
lymph- 
ocytes, 


Eosin- 
ophils, 




Leucoeytes 


mor- 
phonu- 
clear 


Small 
lymph- 
ocytes, 


Eosin- 
ophils, 






cells, 
per 


per 

cent. 


per 
cent. 






cells, 
per 


per 

cent. 


per 
cent. 






cent. 










cent. 






Before 


24,200 


86 


9 


3 


Before 


24,000 


71 


12 


6 


1 day 


18,600 








lday 


24,000 


92 


4 


1 


2 days 


56,000 








4 days 


28,600 








3 days 


28,400 


73 


8 


12 


8 days 


36,000 








6 days 


52,000 








10 days 


38,400 


81 


11 





8 days 


51,000 


85 


6 


5 


12 days 


31,200 


76 


18 


2 


11 days 


42,400 


73 


13 


8 


14 days 


18,200 


68 


21 


2 


14 days 


31,100 


63 


25 


5 


17 days 


17,800 


73 


24 


1 


17 days 


17,200 








20 days 


13,200 


60 


32 


2 


28 days 


13,000 


54 


20 


20 


24 days 


14,100 


66 


26 


5 


41 days 


18,000 


60 


20 


16 


28 days 


19,100 








51 days 


16,800 


54 


20 


17 


31 days 


11,900 


61 


28 


5 


62 days 


18,000 


65 


17 


14 


44 days 


16,100 








79 days 


17,200 


51 


24 


20 


59 days 


11,200 








93 days 


16,400 








66 days 


25,000 


78 


15 


5 


100 days 


12,200 








72 days 


22,400 








136 days 


10,000 


50 


23 


24 


86 days 

95 days 

107 days 


19,100 
12,800 
10,200 


67 


22 


2 


Normobh 


ists and 


polychromatc 


philia 


Normoblasts prese] 


it afte 


r inject 


ion of 


constan 


tly presen 


t after inject] 


on of 


serum for 17 da 


ys, no 


ne thei 


reafter. 


serum x 


mtil 28th 


day. One n 


ormo- 


Polychromatophil 


La less 


marke( 


I than 


blast se 


3n in last ( 


jount 




in dog 51 









* The data in this table are arranged in the same manner as in Table XXVII. 

It is evident that hemolytic serum causes in the sple- 
nectomized dog a leucocytosis which runs higher than 
that in the normal dog. The increase in cells is chiefly 
in the polymorphonuclear leucocytes, though there is in 
both normal and splenectomized animals a moderate in- 



REGULATORY INFLUENCE OF THE SPLEEN 109 

crease in the lymphocytes and in the latter a persisting in- 
crease in the eosinophiles. 

Another interesting point concerns the change in re- 
sistance of the red cells after administration of hemolytic 
serum. As has been shown in an earlier chapter, the in- 
creased resistance of the red blood-cells of the splenecto- 
mized animal to the action of hypotonic salt solution and 
to hsemolytic serum is " not due to an increased anti-ha?mo- 
lytic power of the animal's serum or to a diminished com- 
plementary value of the serum, but is a property of the 
erythrocytes themselves." In the course of the present 
investigation it was noted that shortly after the adminis- 
tration of hsemolytic serum the cells of the splenectomized 
animals, instead of showing a greater resistance to hypo- 
tonic solution, became less resistant, and this decreased 
resistance persisted in the splenectomized animal for a 
longer period than in the normal animal. This is shown 
in the following abridged table: 

TABLE XXXII 



Resistance of Red Blood-Corpuscles After Injection of Hemolytic 

Serum * 


Dog 51. (26 days after splenectomy) 


Per cent, salt solution 


0.25 


0.3 


0.35 


0.4 


0.45 


0.5 


0.55 


0.6 


Before serum was administered 


+ 
+ 
+ 
+ 
+ 
+ 


+ 
+ 
+ 
+ 
+ 
+ 


P 
P 
P 
P 
P 
P 


P 
P 
P 
P 
P 
P 


O 
P 
P 
P 
P 




O 
O 
P 
P 





O 

o 
p 
p 





o 


3 hours after serum was administered 


o 


6 days after serum was administered 


p 


8 to 34 days after serum was administered 

41 to 76 days after serum was administered 

100 days after serum was administered 


p 
o 
o 






Dog 53. Normal 


















Before serum was administered 


+ 
+ 
+ 
+ 


+ 
+ 
+ 
+ 


P 
P 
P 
P 


P 
P 
P 
P 




p 
p 
p 




P 
p 






p 
p 




o 


18 hours after serum was administered 


o 


8 to 12 days after serum was administered 

20 to 95 days after serum was administered 


p 





* + indicates complete haemolysis; P, partial haemolysis; and O, no haemolysis. 



110 THE SPLEEN AND ANEMIA 

Here it is seen that the erythrocytes of the splenecto- 
mized and the normal dog had the same resistance to salt 
solution before the injection, and likewise the same de- 
crease in resistance eight days after the in j ection of haemo- 
lytic serum. The cells of the normal animal, however, 
returned to almost the original resistance after twenty 
days, while those of the splenectomized animal did not 
return to the same degree until the forty-first day. On 
the other hand, it will be seen that the splenectomized ani- 
mal returned to the original point after one hundred days, 
while the normal animal failed to do so after ninety-five 
days. 

In the anaemia produced by sodium oleate the de- 
creased resistance, although it occurs, is not so striking 
in either the normal or the splenectomized animal as it is 
in the anaemia caused by haemolytic serum; the splenecto- 
mized animal, however, always shows a greater decrease 
in resistance than does the normal. 

These observations may be summarized as follows: 

In the splenectomized dog the anaemia caused by haemo- 
lytic poisons (haemolytic immune serum and sodium oleate) 
and by bleeding usually develops more gradually, is gen- 
erally of a severer grade, runs a longer course, and is 
accompanied by a less rapid regeneration of the blood 
than is the case in the normal dog. Also, in the splenecto- 
mized dog, especially after the use of haemolytic serum, 
the leucocytosis is greater than in the normal animal. 

The splenectomized dog almost uniformly exhibits an 
increased resistance of the red cells to hypotonic salt solu- 
tion, but after the administration of haemolytic poisons, 
and especially haemolytic serum, this increased resistance 
disappears and a decreased resistance persists for varying 



REGULATORY INFLUENCE OF THE SPLEEN 111 

periods of time. The same change oceurs in the normal 
dog, but in the latter the return to the previous or even 
increased degree of resistance is more rapid than in the 
splenectomized animal. 

These results show that, although splenectomy leads to 
an increased resistance of the red blood-cells and to their 
slower destruction on the administration of a haemolytic 
agent — one factor in the lessened tendency to jaundice 
and to haemoglobinuria — yet there persists that same ob- 
scure disturbance which induces the anaemia occurring early 
after splenectomy, and which remains present, although 
latent for months, rendering any new haemolytic agent 
more effective and delaying the recovery from the anaemia 
which it causes. 

It would appear, therefore, that of the phenomena as- 
sociated with the absence of the spleen, two — the increased 
resistance of the red cells and the decreased tendency to 
jaundice after the administration of haemolytic poisons — 
are correlated, but that the anaemia itself is dependent upon 
some factor, as yet unknown, which operates in the ab- 
sence of the spleen. After the administration of a hsemo- 
lytic agent to a splenectomized animal this unknown factor 
dependent on the absence of the spleen prolongs the 
anaemia and retards repair, and the animal does not recover 
as quickly as does the normal animal. This, at the present 
stage of our knowledge, is the only explanation of the more 
severe and more prolonged anaemia occurring in splenecto- 
mized animals receiving haemolytic agents. Nevertheless, 
the increase in the red blood-cell count that we have found 
to follow the intraperitoneal injection of splenic extract 
suggests that the normal spleen exerts a stimulating effect 
on the bone-marrow, which naturall} 7 is lost after splenec- 



112 THE SPLEEN AND ANAEMIA 

tomy. It is probable that this loss may at least contribute 
to the retardation of repair in splenectomized animals, but 
the evidence on this point is insufficient to allow definite 
conclusions. 

5. The Influence of the Spleen Upon Iron 
Metabolism 

This investigation was undertaken to determine 
whether the tendency to anaemia in splenectomized dogs 
and the delayed regeneration of the blood, after the admin- 
istration of hemolytic agents to such dogs, might be due 
in part to some influence of the spleen upon the iron metab- 
olism, as has been claimed by Asher and his co-workers. 

Our present knowledge concerning iron metabolism 
may be summarized as follows : Iron is absorbed to only 
a very limited extent from the gastro-intestinal tract, so 
that when abundant in the food it passes from the intestine 
for the most part unchanged. As much as is absorbed is 
taken up chiefly from the small intestine and carried by 
the lymph, to be deposited in the liver and to a lesser extent 
in the spleen, bone-marrow, and perhaps elsewhere, and 
this occurs whether the iron be in intimate organic com- 
bination, the so-called food iron, incapable of giving the 
characteristic microchemical reaction, or whether it be in 
the form of an organic or inorganic salt of iron. Moreover, 
from the work of Hausermann l7 ° and of Abderhalden, 1 
it appears that, though iron salts are absorbed, the body 
is unable, or but very poorly able, to utilize them for the 
building of haemoglobin, being dependent for this construc- 
tive work upon the intimately combined food iron. On 
the other hand, iron salts are effective stimulants to the 



REGULATORY INFLUENCE OF THE SPLEEN 113 

blood-forming organs and conspicuously increase the utili- 
zation by them of the food iron. 

The elimination of iron occurs almost wholly through 
the intestines, especially the colon, the quantity passing 
out in the urine constituting less than one per cent, of the 
total excretion in man and the dog. In the fasting dog 
the output found by Voit 458 was 0.60 mgm. per kilo, of 
body weight per day, and on an adequate but iron-poor 
diet Gottlieb's 151 dog excreted 0.34 mgm. For man the 
figures are lower. Cetti and Breithaupt, 70 while fasting, 
eliminated about 0.10 to 0.13 mgm. per kilo, per day, 
and in various studies on man 0.10 to 0.25 mgm. per kilo, 
per day have been found to be the intake required to 
maintain iron equilibrium. However, there is every rea- 
son to believe, as is suggested by the work of Schmidt, 395 
who fed mice for months on a diet extremely poor in iron, 
but obtained no fall in the haemoglobin, that the organism 
possesses great power of conserving its iron and of reutil- 
izing it through some form of intermediary metabolism. 
When, however, Schmidt withdrew iron from the diet for 
several generations, the younger generations were ex- 
tremely anaemic, and this anaemia disappeared upon re- 
storing iron to the diet. As the iron-poor diet led to the 
disappearance of microchemically demonstrable iron from 
the liver, but affected to a much slighter degree that of 
the spleen, Schmidt concluded that the liver is the depot 
for iron from the food, and that the spleen, on the other 
hand, is the depot for iron from tissue and erythrocyte 
catabolism, and thus an important factor in the interme- 
diary metabolism of iron. 

If the spleen plays this part in iron metabolism, its 
absence might well interfere with the reutilization of iron 



114 THE SPLEEN AND ANAEMIA 

by the organism and lead to an increased iron elimination, 
and this Asher 14 and his co-workers, Grossenbacher 16 
and Zimmermann 19 claim to have demonstrated in dogs. 
They studied the iron elimination of four puppies from two 
litters; one from each litter was splenectomized and one 
from each kept as a control. The iron estimations were 
made at intervals of a few weeks, two months, and ten 
months after splenectomy, and in all their experiments they 
found an output much higher, often double, in the sple- 
nectomized animals as compared with the controls. 

Methods. — In our earlier experiments we studied the 
iron elimination during four-day periods, but found that 
such periods led to irregular results. In the work here 
reported, therefore, we present only observations based 
on periods of longer duration. 

The animals were placed in metabolism cages with glass 
floors, and after they had been fed for several days on 
constant weighed amounts of the diet selected the rectum 
was emptied by the use of morphine; iron-free charcoal 
was added to the next feeding and the collection of faeces 
begun from the appearance of the charcoal; at the close 
of the period the rectum was again emptied with morphine, 
carmine added to the next feeding, and the fasces collected 
until carmine appeared in them. In the earlier experi- 
ments the urine also was analyzed, but as only traces of 
iron, less than one per cent, of the total elimination, were 
found the urine was omitted in our later analyses. To 
avoid the introduction of extraneous iron, the fasces were 
collected by means of a nickel spatula soon after being 
passed. 

In one group of experiments representing the earlier 
periods after operation we have studied the output of iron 



REGULATORY INFLUENCE OF THE SPLEEN 115 

on the same dogs, both before and after splenectomy, with- 
out a change in diet. In another group, representing later 
periods, we have compared the output of normal control 
dogs with that of splenectomized dogs of approximately 
the same weight on corresponding diets. 

The analyses were made by the method of Ripper and 
Schwarzer, 376 slightly modified. The faeces collected for 
the entire period are placed in a quartz dish, dried, and 
ashed diy. The ash is extracted with boiling concentrated 
hydrochloric acid and filtered, and the residue washed with 
20 per cent, hydrochloric acid. The residue and filter- 
paper are re-ashed and the extraction repeated. This ash- 
ing and extraction is continued until the extract ceases 
to give a positive test with KCNS. 

The total filtrate is made up to a known volume and 
two duplicate portions, containing presumably 2 to 5 mgm. 
of Fe are taken. To each is added 1 c.c. of Merck's Blue 
label H 2 2 , and the solution evaporated to dryness on a 
water-bath. The residue is then redissolved in 1 c.c. of 
20 per cent. HC1 and 20 c.c. of boiling water used in four 
small portions, and then this washing with acid and water 
is repeated. In the course of this manipulation the entire 
solution is brought into a 200 c.c. Erlenmeyer flask. 

All the specimens to be analyzed at any one time having 
been brought to this stage, a standard is prepared by plac- 
ing in each of two 200-c.c. Erlenmeyer flasks 40 c.c. of a 
quantitative Fe 2 Cl G solution containing about 0.002 gm. 
Fe. To each of the flasks, those containing the specimens 
and the two containing the standard, there are added in 
rapid succession 4 gms. of KI, the flasks immediately 
stoppered and placed in a water-bath at 60° C. for ten 
minutes. At the end of this time the flasks are removed 



116 THE SPLEEN AND ANAEMIA 

and to each 100 c.c. of cold water are immediately added 
and the flasks restoppered. 

To each flask in turn is added starch solution and the 
contents titrated with sodium thiosulphate solution, ap- 
proximately 1/250 N, until disappearance of the blue 
color, and then immediately titrated with weak iodine solu- 
tion back to the first reappearance of the blue color. In 
each analysis the thiosulphate solution is freshly prepared 
and standardized against the two flasks of known Fe 2 Cl 6 
solution, and the iodine solution also is freshly prepared 
and standardized against the thiosulphate solution. The 
precision of the titration method is found to be greatly 
enhanced by the titration back with iodine to first reap- 
pearance of the blue color, and the calculation accordingly 
of the thiosulphate end point. 

In control experiments performed by adding a known 
amount of iron to one of identical pairs of samples of ash 
of faeces an error of about 2 per cent, was observed. 

The food used in these experiments consisted of casein, 
cracker-meal, lard, and fresh beef heart in proportions 
designed to give the desired amount of iron. The iron 
content of the food was determined by analyzing many 
large portions (each 50 gms. to 400 gms.) of the beef heart, 
cracker, and casein and obtaining average figures for use 
in calculating the iron content of the diets employed. 

Results. — In the accompanying tables are given in 
detail the final figures obtained in our studies. 22 The 
experiments are divided into two groups : First, five ani- 
mals on a constant diet were studied both before and for 
two weeks after splenectomy ; these are arranged in Table 
XXXIII according to the iron content of the diet. Second, 
a group of five animals (Table XXXIV), two of which 



REGULATORY INFLUENCE OF THE SPLEEN 117 



served as normal controls and three for purposes of study 
at longer periods after splenectomy than are represented 
by the group in Table XXXIII. These five dogs were of 
about the same weight and were on diets of the same gen- 
eral character, but varying in the content of iron. 

TABLE XXXIII 
Elimination of Iron Before and After Splenectomy 





Average 
weight 


Duration of 
periods 


Intake * 


Output* 


Time after 
splenectomy 


Dog No. 


Before 
splenectomy 


After 
splenectomy 


88 
30 
35 
44 
79 


7,000 
5,340 
7,720 
9,000 
9,000 


10 days 
9 days 
9 days 
9 days 
9 days 


0.27 
0.30 
0.64 
1.57 
1.71 


0.67 
0.36 

0.87 
1.89 
1.88 


0.70 
0.55 
0.81 
2.10 
2.21 


4-14 days 
1-10 days 
1-10 days 
1-10 days 
6-15 days 



* Figures represent milligrammes of iron per kilo, per day. 

TABLE XXXIV 
Elimination of Iron in Normal and Splenectomized Dogs 

Normal 





Controls 




Dog No. 


Average weight 


Duration of 
period 


Intake * 


Output * 


Time after 
splenectomy 


79 
44 
79 


9,000 
9,000 
9,000 


9 days 
9 days 
9 days 


1.00 
1.59 
1.71 


1.42 
1.89 

1.88 





Splenectomized 



83 

9 

51 



8,400 

8,800 

10,000 



10 days 
9 days 
9 days 



1.42 
1.35 
1.32 



1.39 
1.56 
1.42 



27-37 days 

9 months 

20 months 



* Figures represent milligrammes of iron per kilo, per day. 

Inspection of Table XXXIII shows that the iron out- 
puts of Dogs 88 and 35 was unchanged by splenectomy, but 
that Dogs 30, 44 and 79 showed some increase. On the 
other hand, in Table XXXIV it will be seen that all three 
splenectomized dogs exhibited an output of iron as com- 



118 THE SPLEEN AND ANAEMIA 

pared with the intake closely comparable with that of the 
controls. From these studies it would appear, therefore, 
that during the first two weeks after splenectomy some, but 
not all, dogs show a slight increase in the output of iron, 
but that at one month, nine months, and twenty months 
after splenectomy we find no indication of such increased 
iron output. The occasional evanescent and inconstant 
increase in elimination of iron does not justify the conclu- 
sion that the spleen exerts an important influence on iron 
metabolism. Our results are obviously different from those 
of Asher and his associates, and as a possible explanation 
of this we would call attention to the extreme shortness 
of the periods — one to three days — employed by Asher 
and Grossenbacher, and to their failure to mark in any 
way the stools. In the studies of output ten months after 
splenectomy, as given by Asher and Zimmermann, the 
splenectomized dog in most of the experiments was much 
larger than the control, so that if the iron output of their 
dogs be calculated per kilo, of body weight it will be found 
that the output of the splenectomized animals approaches 
very closely that of the normal controls and is in some 
instances identical. It seems possible that in these studies 
ten months after splenectomy the apparent increase in iron 
output of the splenectomized animals was due rather to 
the size of the animals than to the splenectomy, and it is 
doubtful, therefore, whether the conclusions of Asher and 
Zimmermann, based on these experiments, are justified. 

It is, however, difficult to explain the slight increase 
in the elimination of iron in three of five of our dogs during 
a period of two weeks following splenectomy. In our dis- 
cussion 22 of this first study of iron metabolism we stated 
that possibly the occasional increased output of iron might 



REGULATORY INFLUENCE OF THE SPLEEN 119 

have some relation to the anaemia which occurs in the early 
weeks after splenectomy and which varies in degree in 
different animals. Later investigations offer some sup- 
port to this hypothesis. In a recent study 149 in which four 
dogs were used in an investigation of nitrogen metaholism 
before and after splenectomy the elimination of iron in the 
fasces was determined. The methods used differed from 
the earlier study in that in all animals the iron elimination 
was determined before splenectomy and during one to three 
periods after splenectomy, and also in that Neumann's 
method 315 of determining iron was used instead of the 
Ripper- Sch war zer method. The periods of study varied 
from five to eight days and represented intervals of three 
days to three months after splenectomy. As the dogs were 
kept in all periods on the same diet, in both quantity and 
quality, the iron intake was not determined. The results 
are presented in Table XXXV. 



TABLE XXXV * 
Iron Elimination Before and After Splenectomy 



Dog No. 


Before splenectomy 


After splenectomy 


Period I 


Period II t 


Period III f 


Period IV f 


48 
52 
56 
57 


17.6 

10.5 

7.4 

10.9 


17.9 

10.4 

9.0 

10.8 


16.8 

9.8 

18.4 


9.9 



* The figures in this table represent milligrammes of iron per day in faeces, 
t The periods after splenectomy were 14 and 55 days for dog 48; 13, 41, and 70 days for 
dog 52; 10 and 86 days for dog 56, and 3 days for dog 57. 

In three of four dogs no important change in the elimin- 
ation of iron occurred after splenectomy. In the fourth 
(Dog 56) there was an increase of 1.6 mg. per day during 
the period (ten days) immediately after splenectomy, 
amounting to an increase of 21.6 per cent, over the fore- 



120 THE SPLEEN AND ANAEMIA 

period. In the final period three months after splenectomy 
the output showed an increase of 148 per cent, over the 
fore-period and double that of Period II. The intake of 
iron was not determined, but, since the food intake was 
constant throughout all the periods, we have reason to be- 
lieve that this was a constant factor. Of the four animals, 
two showed no anaemia and a third only a slight reduction 
in haemoglobin and red cells. The fourth dog (No. 56) 
showed a relatively severe anaemia (see Table LIII in sec- 
tion devoted to metabolism) . As this last dog was the only 
one to show any unusual elimination of iron after splenec- 
tomy, the question naturally arises : Is the increased elimi- 
nation of iron due to the anaemia or to the absence of the 
spleen? We incline to the former view and conclude that 
the spleen exerts no constant and important influence upon 
iron metabolism.* 

* One other attempt to elucidate the iron problem has been the 
feeding of an inorganic salt of iron before and after splenectomy. 
Such experiments in the normal animal are, as a rule, of little value, 
as iron so administered is not absorbed to any appreciable extent, but 
is eliminated almost completely. 164 It seemed worth while, however, 
to see if any change in absorption occurred in the absence of the spleen. 
Two dogs on the usual constant diet were, therefore, fed daily 55 mgm. 
of iron as ferrous sulphate during a period of one week before and a 
like period after splenectomy. In each instance the second period of 
analysis began four days after splenectomy. No essential or constant 
difference was found in the elimination of the two periods. In one 
animal, of 55 mgms. of iron given daily, 52 mgm. were eliminated 
daily before and 50.5 after splenectomy; in the other animal the figures 
were 51.2 before and 52.5 after splenectomy: essentially negative 
results. 



CHAPTER V 

CONTROL EXPERIMENTS: THE DIVERSION OF THE 

SPLENIC BLOOD FROM THE LIVER WITHOUT 

REMOVAL OF THE SPLEEN 

(1) BY LIGATION OF THE SPLENIC VEIN, (2) BY 
TRANSPLANTATION OF THE SPLENIC VEIN INTO 
THE VENA CAVA, (3) BY ECK FISTULA. 

Hitherto in all our discussions of the phenomena 
following splenectomy — the anaemia, the increased resist- 
ance of the red cells, and the decreased tendency to jaun- 
dice — we have assumed that, inasmuch as the spleen was 
absent, the changes described are probably due to the 
loss of some function peculiar to that organ. 

As to the exact nature of the function lost, no definite 
opinion has thus far been given. Three possibilities, how- 
ever, readily suggest themselves: (1) The loss of some 
function of blood destruction or regeneration resident in 
the spleen itself ; ( 2 ) the loss of an internal secretion acting 
on the distant hemopoietic tissues, as the bone-marrow, 
and (3) the obliteration of the venous drainage of the 
spleen, which, in that it is an important source of the portal 
blood, may have an essential relation to some peculiar 
function of the liver. It is obvious that the value of some 
of these hypotheses might be tested without removal of 
the spleen by diverting its venous outflow from the liver. 
We have therefore repeated 229 many of our experiments, 
but, instead of removing the spleen, the splenic vein has 
either been ligated or transplanted in the vena cava, or an 
Eck fistula has been established. So far as we know, 
exactly similar experiments have not previously been at- 

121 



122 THE SPLEEN AND ANAEMIA 

tempted, though two observations have a bearing on the 
problem. Nassau 313 found that the number, color, and 
resistance of the red cells remained unchanged after simple 
Eck fistula, but, as he gives only one count before and 
one after the operation, his observations are not conclusive. 
The other report which concerns us is Pribram's 361 arti- 
ficial constriction of the splenic vein with resultant passive 
congestion of the spleen. The slight anaemia that this 
caused is analogous to some of the results we report below. 

If the anaemia following splenectomy is caused by the 
removal with the spleen of some necessary factor in blood 
formation or of a hormone essential to the haemopoietic 
tissues, this factor should not operate in the vein trans- 
plantation and Eck fistula experiments unless it is also 
essential that such a substance have direct approach to 
the liver for its proper functioning or activation. If, on 
the other hand, the anaemia is largely due to the inter- 
ference with the supply of splenic blood to the liver, it 
should occur in all the animals. These problems and also 
that concerning the influence of the experimental pro- 
cedure on increased resistance of the red cells will be con- 
sidered first, and then problems such as the decreased 
tendency to jaundice and the prolonged repair of anaemia 
in the splenectomized animal when haemolytic agents are 
given. 

Methods. — In the ligation experiments it was found 
necessary, on account of the numerous branches and the 
anastomoses of the splenic vein with veins from the 
stomach, to tie all branches of the splenic vein shortly after 
they left the spleen. In the earlier operations one of the 
subdivisions of the artery was also ligated, to lessen the 
supposed danger of rupture. This, later, was abandoned 



CONTROL EXPERIMENTS 123 

when it was found to be unneeessary as well as undesirable 
on account of infarct production. Post-mortem examina- 
tion of animals subjected to this operation showed in each 
case that all branches had been tied, that the vessel beyond 
the ligation was much diminished in size or completely 
obliterated, and that there was usually little attempt at 
compensatory development of new veins from the adherent 
omentum. When such new-formed veins were present it 
was found that seldom did they empty into the portal system 
and therefore, as a rule, did not complicate the experiment. 

Eck fistula was performed in the usual manner, the 
proximal end of the portal vein being tied off above its 
new anastomosis with the vena cava just before its entrance 
into the liver. Transplantation of the splenic vein into the 
inferior vena cava presented considerable difficulty on 
account of the smallness of the vein and the necessity of 
stretching it a little to make it reach the vena cava. In only 
one experiment, however, was it found that the trans- 
planted vein had been occluded by thrombus. The success 
of the operation was always determined by examination 
of the vessels at autopsy, and in some instances injection 
specimens were prepared and dissected to make doubly 
sure that no new anastomoses had formed. 

The particular phenomena studied were ( 1 ) the quanti- 
tative changes in counts of the red blood-cells, leucocytes, 
and haemoglobin; (2) the resistance of the red cells to 
hypotonic salt solution; (3) the general condition of the 
animals as indicated by their weight and condition of the 
urine, and (4) the gross and microscopical appearance of 
the organs at autopsy. 

The dogs were kept on the usual mixed diet of " table 
scraps," which has been shown to maintain properly normal 



124 THE SPLEEN AND ANAEMIA 

dogs as well as those convalescing from operations other 
than splenectomy without the development of anaemia. 337 
Our studies have been made on twelve dogs, grouped 
as follows: Ligation of splenic vein, 4; transplantation 
of splenic vein, 2; Eck fistula, 2; and as controls: Sple- 
nectomy, 3; transplantation of the inferior mesenteric 
vein, I. In the case of the last dog it was intended to 
transplant the splenic vein, and it was not until autopsy 
that we found that the inferior mesenteric vein had been 
used by mistake. 

Changes in the Spleen 
In those dogs in which all branches of the splenic vein 
had been ligated, and in which adequate new venous chan- 
nels had failed to develop, the spleen showed considerable 
change. Before the operation was completed the spleen 
had increased to almost double its size and taken on a dark- 
purple color. If the animal was allowed to survive two 
or more months the spleen, at autopsy, was found to be 
considerably smaller and much firmer than normal. The 
capsule was slightly thickened and puckered, and the 
organ had a pale-bluish color. On section the tissue cut 
with increased resistance. A few small shrunken infarcts 
were occasionally found. The cut surface was less bloody 
than usual and showed an increase of fibrous tissue, with 
indistinct Malpighian corpuscles. Histologically, the tis- 
sue appeared to be condensed, with collapse of the sinuses, 
rather than to exhibit true fibrous hyperplasia. Some 
hemosiderin pigment was found, the Malpignian cor- 
puscles were small, and here and there were small areas 
of hyaline degeneration which did not respond to Lugol's 
test. Thromboses were not found except in connection 



CONTROL EXPERIMENTS 125 

with old post-operative infarcts. In the earlier experiments 
in which a branch of the artery was also ligated a bulging 
hemorrhagic infarct appeared in the corresponding area 
of the spleen. The neighboring lymph-nodes and the 
liver were apparently unchanged. Speculation as to the 
adjustment of the splenic circulation in these cases must 
remain unsatisfied. The most probable explanation seems 
to be that the elastic spleen is able not only to accommo- 
date the increasing pressure without rupture, but, with 
the aid of the minute capillaries in the adherent omentum, 
to maintain sufficient degree of nutrition to prevent necro- 
sis. We have seen, however, that the exchange is not 
sufficient to prevent atrophy. 

At the time of the operation for Eck fistula and the 
splenic vein-vena cava anastomosis there is necessarily a 
temporary occlusion of the large veins. The spleen and 
intestines become very dark and turgid, but when the 
clamps are removed these organs return quickly to normal 
color. In animals so treated no changes are found at 
autopsy except adhesions and perisplenitis. 

Changes in the Blood 

An example of the changes in the blood which occur 
after ligation of the splenic vein is given in Table XXXVI. 

It may be seen that this animal developed a moderate 
degree of anaemia lasting several weeks and similar to, but 
less severe than, that following splenectomy. The anaemia 
is accompanied by a temporary slight increase in resistance 
of the red cells to hypotonic salt solution. As in splenec- 
tomy, there is an immediate leucocytosis, due to polymor- 
phonuclear and transitional forms, but prolonged by a 
more persistent lymphocytosis and eosinophilia. 



126 



THE SPLEEN AND ANAEMIA 



A very slight drop in weight occurs after operation, 
but later there is a distinct increase above the original 
weight. It has been shown elsewhere, 337 by the study of 
control operations such as nephrectomy, that the results 
here described are not merely post-operative. Other dogs 
with ligated veins gave similar results, as, for example, 

TABLE XXXVI 

Blood Changes Following Ligation op Splenic Veins 



Dog 47 


a 

ii 

o 

a 
w 


Red blood 
cells per 

cmm. 


Haemolysis * 


in 

<u . 

>>a 

i-3 


■ 

o 

A 
gun 

O c3 

o a 


o 
a 

a 
>, 

~* <n 

a © 

CO 


"3 
a 
S 

8.3 

%° 

oj -3 

Hi 


ft 
O 

.9 

o 

m 






Begins 


Com- 
plete 


to 
"3 


Before 

1 day after 

4 days after 

1 week after 

2 weeks after 

3 weeks after 

4 weeks after 

5 weeks after 
7 weeks after 

10 weeks after 

12 weeks after 

13 weeks after 

14 weeks after 


per 
cent. 

102 
98 
92 
90 

72 
70 
78 
74 
80 
82 
95 
92 
95 


6,275,000 
6,110,000 
5,350,000 
5,520,000 
4,900,000 
4,600,000 
5,000,000 
4,380,000 
5,040,000 
5,050,000 
5,830,000 
6,410,000 
6,150,000 


0.475 

0.475 
0.425 
0.425 
0.45 

0.475 
0.45 
0.475 
0.475 


0.35 

0.275 
0.275 
0.3 
0.3 

0.275 
0.3 
0.325 
0.35 


9,800 
19,000 
16,500 
16,800 
18,800 
21,000 
18,600 
15,000 
12,800 
12,400 
14,800 
14,900 
15,600 


7,200 
15,200 

13,600 
15,400 
16,800 

10,000 

9,500 

9,200 

12,200 


700 
950 

1,300 
1,900 
3,100 

1,700 

3,400 
3,600 
2,500 


1,800 
2,850 

1,600 

1,500 

300 

1,100 

1,500 

1,200 

600 


100 


300 



300 



400 
900 
100 


kilos. 

6.0 
5.7 
5.6 
5.4 

6.4 
7.3 
7.5 
7.4 



* The figures in these columns refer to the strongest percentages of salt solution in which 
haemolysis was first noticed and in which complete haemolysis first occurred. 

Dog 51 with a maximum drop of 14 per cent, of haemoglo- 
bin and 1,200,000 red cells, and Dog 74 with a haemoglobin 
loss of 24 per cent, and in red blood-cells of 1,800,000. 

The effect of diverting the splenic venous blood from 
the liver by transplanting the splenic vein into the vena 
cava is shown in Table XXXVII. 

Many of the same changes as after ligation are found 



CONTROL EXPERIMENTS 



127 



here. In another dog (No. 71) similarly treated the in- 
creased resistance was much more marked : before opera- 
tion, haemolysis began at 0.50 and was complete at 0.3.5: 
soon after operation it began at 0.425 and was complete 
at 0.25. Anaemia was also present, as shown by a drop of 
20 per cent, in haemoglobin and of 1,800,000 red blood- 
cells. A third animal (16) lost 35 per cent, haemoglobin 

TABLE XXXVII 

Blood Changes Following Anastomosis of the Splenic Vein With the 

Vena Cava 





a 




Hemolysis * 


■ 


o 


c 


a * 






a 


Red blood 




u 


If 


E 


— - 


IE 




Dog 4 


M 


cells per 






o g 


z ■ 


— ' 33 




o 


« 




\ 


cmm, 


Begins 


Com- 


3 © 


> z 


— - 


si 


£ 


3 

•s 




w 




plete 


© a 


c s 


E - = '- 

B0 | - 


a 




per 
cent. 










J 




kilo: 


Before 


97 


6,960,OOo' 0.45 


0.35 16,100 ! 8,400 


4,700 ,1,6001,40c 


9.4 


1 day after 


104 


7,040,000 0.425 


0.3 34.000 29,600 


3,100 1,300 




1 week after 


75 


5,550,000 0.45 


0.3 19.300 12,400 


3,700 1,9001,300 9.7 
2,700 2,200, 200J 9.4 


2 weeks after 


68 


5.020,000 0.475 


0.275 16,900 11,800 


3 weeks after 


70 


4,530,000, 






9.6 


4 weeks after 


80 


4,510,000 0.475 


0.3 14,700 


9,600 


2,800 1.500 SOQ 10.4 


5 weeks after 


74 


5,440.000 0.475 


0.325 14.000 9,800 


2,800 4201,080 10.5 
4,000 560 36q 


6 weeks after 


78 


5,630.000 0.45 


0.3 11,200 


6,300 


7 weeks after 


82 


5,770,000 0.45 


0.325 11,100 


7,400 


2,900 200 600 12.9 


8 weeks after 


85 


6,060.000 0.45 


0.325 










9 weeks after 


96 6,500,000 










13.2 



* The figures in these columns refer to the strongest percentages of salt solution in which 
haemolysis was first noticed and in which complete haemolysis first occurred. 

and over 2,000.000 erythrocytes, and a fourth, 22 per cent. 
haemoglobin and over 1,000,000 erythrocytes. 

The changes in an Eck fistula experiment are seen in 
Table XXXVIII. 

In another Eck fistula dog (Xo. 68) the increased re- 
sistance of the red cells was more marked (before opera- 
tion, haemolysis began at 0.45 and was complete at 0.3; 
soon after operation it began at 0.425 and was complete 



128 



THE SPLEEN AND ANAEMIA 



at 0.225), and the animal lost 33 per cent, haemoglobin 
and 2,000,000 red blood-cells in four weeks' time after 
operation. In a third ( No. 5 ) with an even greater drop, 
the blood picture was complicated by the occurrence of 
infection, for which reason the figures are not given. 

That interference with the portal circulation inflow 
from organs other than the spleen may cause changes in 

TABLE XXXVIII 
Blood Changes Following Eck Fistula 





a 
'Z 

o 
% 
o 

a 
a 
W 


Red blood 

cells per 

cmm. 


Haemolysis * 


to 

>>a 

:§ 

o w 

-.. n 


o 

A 

£•« 

O 03 

S.52 
a 



a 

a 

a 
>> 

■""' to 
*"& 

So 

w 


•55 

el 


co 

A 
O 

.5 






Dog 31 


Begins 


Com- 
plete 


to 
■53 


Before 
1 day after 
3 days after 
5 days after 

1 week after 

2 weeks after 

3 weeks after 

4 weeks after 

5 weeks after 

6 weeks after 

7 weeks after 

8 weeks after 


per 

cent. 

99 
88 
84 
72 
74 
68 
73 
67 
72 
84 
90 
98 


6,500,000 
6,040,000 
6,300,000 
5,400,000 
5,500,000 
5,040,000 
5,110,000 
4,460,000 
4,880,000 
5,600,000 
6,200,000 
6,520,000 


0.45 

0.475 

0.45 

0.425 

0.425 

0.425 

0.425 

0.425 

0.475 

0.475 

0.45 

0.45 


0.325 

0.325 

0.325 

0.3 

0.3 

0.275 

0.275 

0.3 

0.325 

0.325 

0.3 

0.3 


13,200 
36,000 
32,400 
24,000 
18,800 
19,600 

21,000 
18,400 
16,000 
15,200 
15,800 


9,800 
32,400 
27,500 
17,300 
13,700 
15,500 

15,500 
12,900 
10,500 
10,300 
11,400 


2,700 
2,800 
2,900 
3,800 
3,400 
3,900 

4,400 
3,700 
3,800 
2,800 
3,500 


500 
800 
1,600 
2,400 
800 
600 

600 
600 
400 
600 
300 


200 



400 

500 

900 

600 

500 
1,200 
1,300 
1,500 

600 


kiloa. 

16.1 

14.2 
14.2 
13.6 
13.5 

14.6 
14.2 
14.9 
15.3 
15.4 



* The figures in these columns indicate the percentages of salt solution in which haemolysis 
was first noticed and in which haemolysis first became complete. 

the hlood is shown in another experiment (see Table 
XXXIX ) in which the inferior mesenteric vein was anas- 
tomosed with the vena cava. • 

This dog developed an anaemia of mild grade and re- 
covered from it sooner than did the other dogs of this series. 
Although little weight can be placed on a single experi- 
ment such as this, the observation tends to support the 
theory that the supply of portal blood to the liver is a 



CONTROL EXPERIMENTS 



129 



factor in the production of the changes we have observed 
to occur after splenectomy. 

From these observations the following conclusions may 
be drawn: 

1. In dogs in which the splenic vein has been ligated or 
transplanted into the inferior vena cava, or in which an 
Eck fistula has been made, an ansemia occurs which re- 

TABLE XXXIX 

Blood Changes Following Transplantation of Inferior Mesenteric 
Vein. Control Experiment 





Haemo- 
globin 


Red blood cells 
per cmm. 


Haemolysis * 




Dog 55 


Begins 


Complete 


Weight 




per cent. 








kilos. 


Before 


100 


5,940,000 
5,240,000 


0.45 


0.3 


14.7 


2 days after 


76 


0.4 


0.25 




3 days after 


75 


5,100,000 


0.4 


0.25 


13.9 


10 days after 


76 


4,880,000 


0.45 


0.275 




2 weeks after 


85 


5,400,000 


0.425 


0.25 




3 weeks after 


84 


5,890,000 


0.425 


0.25 




4 weeks after 


78 


5,600,000 






14.7 


5 weeks after 


88 


5,720,000 








6 weeks after 


92 


5,800,000 


0.425 


0.275 


15.3 



* The figures in these columns indicate the percentages of salt solution in which haemolysis 
was first noticed and in which haemolysis first became complete. 



sembles that following splenectomy and shows the same 
general variations in degree and duration. 

2. The resistance of the red cells to hypotonic salt solu- 
tion is quickly increased, sometimes coincident with and 
sometimes preceding the ansemia. It gradually returns to 
normal in about the same length of time as it takes the 
ansemia to disappear, differing in this particular from 
the results after splenectomy. 

3. There is an initial leucocytosis, involving at first 
the polymorphonuclear leucocytes and transitional cells. 
As the total leucocytosis diminishes there is both a relative 

9 



130 THE SPLEEN AND ANAEMIA 

and actual increase of small lymphocytes and usually also 
of eosinophiles. This may either be temporary or last 
during the rest of the period of observation, and thus 
differs from the ordinary postoperative leucocytosis. 

4. Ligation of the splenic vein is followed by consid- 
erable atrophy of the spleen, but not by necrosis or throm- 
bosis. There is rarely adequate new vein formation. The 
other operations cause little or no change in the spleen. 

5. Whether the disturbances described are due to the 
loss of a certain volume of blood to the liver, or, as has 
been previously suggested, to the loss of a splenic hormone 
acting on the hsemopoietic tissues, it is impossible to say. 
If due to the former, the method of production of the 
ansemia still remains unexplained. It is evident, also, that 
the latter theory has no value unless it is assumed, also, 
that the supposititious hormone normally is activated by 
passage through the liver. 

RESISTANCE TO HEMOLYTIC AGENTS 

In the previous pages has been discussed the effect 
upon the blood picture of three methods (transplantation 
of the splenic vein into the vena cava, Eck fistula, and 
ligation of the splenic vein) of diverting the splenic blood 
from the liver. It now remains to present the results of 
a study of the influence of these procedures on the action 
of hsemolytic agents. Do they bring about a decreased 
tendency to jaundice when a hsemolytic agent is given and 
retard the repair of an artificially produced ansemia, as is 
the case in splenectomized animals? 

As Hsemolytic agents we have employed both toluylene- 
diamine and hsemolytic immune serum. The hsemolytic 
serum was prepared by injecting, at regular intervals, the 



CONTROL EXPERIMENTS 



131 



erythrocytes of the dog into rabbits. All injections of 
serum so prepared were made intravenously into the dog. 
Merck's meta-toluylenediamine was given by stomach-tube, 
and in adequate doses never failed to cause anaemia and 
jaundice. In each experiment the control animal received 
the same proportionate amount of drug or serum per kilo, 
of body weight as did the test animal. Dogs of approxi- 
mately the same size were selected, and, on account of the 
occasional necessity of catheterization, female dogs were 
used whenever available. Splenectomized as well as nor- 
mal animals were included in the series to further com- 
parison with our previous results. Daily and, later, weekly 
examinations of urine and complete blood examinations 
(including resistance of erythrocytes to hypotonic salt solu- 
tion) were made and records of weight were kept. Each 
animal was studied as to condition of urine and blood be- 
fore the experiment. Both cage urine and catheterized 

TABLE XL 
Jaundice After Administration of Tolutlenediamin (0.34 Gm. Per Kilo.) 





Dog 71 


Dog 79 


Dog 51 


Dog 75 
Normal control 


Time after 


Splenic vein trans- 
plant (2 mos.) 


Splenectomy 
(1>£ mos.) 


Ligation 
(2 mos.) 


administration 


0.425 B. H.- 


0.40 B. H.- 


0.45 B. H - 


0.425 B. H- 




0.325 C. H.* 


0.275 C. H. 


0.275 C. H. 


0.275 C. H. 




No anaemia 


No anaemia 


Slight anaemia 


No anaemia 


Before 


Urine normal 


Urine normal 


Urine normal 


Urine normal 


1 day after 


Bile trace 


Bile slight 


Bile moderate 


Bile marked 


3 days after 


Bile heavy trace 


Bile slight 


Bile moderate 


Bile marked 


5 days after 


Bile trace 


Bile moderate 


Bile moderate 


Bile marked 


7 days after 


Bile absent 


Bile moderate 


Bile moderate 


Bile marked 


9 days after 


Bile absent 


Bile moderate 


Bile moderate 


Bile moderate 


11 days after 


Bile absent 


Bile trace 


Bile faint trace 


Bile trace 


13 davs after 


Bile absent 


Bile trace 


Bile absent 


Bile trace 


15 days after 


Bile absent 


Bile trace 


Bile absent 


Bile trace 


17 days after 


Bile absent 


Bile absent 


Bile absent 


Bile absent 



* This space in this and following tables refers to the condition of the blood before beginning 
the experiment. The figures indicate strength of salt solution at which haemolysis occurs; 
B. H. indicates beginning haemolvsis, C. H. complete haemolysis. Increasing amounts of bile 
in the urine are expressed in the following terms: faint trace, trace, heavy trace, slight, moderate, 
marked. 



132 



THE SPLEEN AND AN.EMIA 



specimens (in doubtful cases) were examined, and the 
presence of bile-pigment in the urine, determined by 
Gmelin's and Rosenbach's tests, was taken as the surest 
evidence of jaundice. At the termination of the experi- 
ment the animals were sacrificed in order to determine the 
exact anatomical disturbance caused by the operation. 

As may be seen in Table XL, in all animals receiving 
toluylenediamine, control as well as experimental, some bile 
appeared in the urine. The bile was less in amount, how- 
ever, and lasted for shorter periods in the test animals than 
in the normal controls. In fact, animals with the vein 
transplant and Eck fistula showed even less tendency to 
jaundice than the splenectomized animal. 

TABLE XLI 
Jaundice After Administration of Tolttylenediamin (0.13 Gm. Per Kilo.) 





Dog 68 


Dog 55 


Dog 77 




Eck fistula 


Mesenteric vein trans- 


Normal control 


Time after 


(1 mo.) 


plant (1}4 mos.) 


No anaemia 


administration 










0.4 B. H.-0.275 C. H. 
Anaemia present 


0.425 B. H.-0.275 C. H. 

No anaemia 


0.425 B. H.-0.35 C. H. 


Before 


Urine normal 


Urine normal 


Urine normal 


1 day after 


Bile absent 


Bile trace 


Bile trace 


2 days after 


Bile faint trace 


Bile trace 


Bile marked 


3 days after 


Bile faint trace ' 


Bile moderate 


Bile moderate 


5 days after 


Bile absent 


Bile doubtful 


Bile moderate 


7 days after 


Bile absent 


Bile absent 


Bile trace 


9 days after 


Bile absent 


Bile absent 


Bile absent 



Another experiment (see Table XLI) in which a 
smaller single dose was administered gave similar results. 
It was in this experiment that the animal that was sup- 
posed to have had the splenic vein transplanted was found 
at autopsy to have a branch of the inferior mesenteric vein 
transplanted by mistake, thus unwittingly causing an excel- 
lent double control for the Eck fistula test (No. 68) . The 
increased resistance to jaundice of this dog (No. 55) as 



CONTROL EXPERIMENTS 



133 



compared to the normal (Xo. 77) is still further evidence 
of the importance of the mechanical factor of blood supply 
to the liver. 

In a third experiment in which three smaller repeated 
doses of toluylenediaminewere given to animals with splenic 
vein transplant and splenic vein ligation and to a normal 
control these results were confirmed. The vein transplant 
dog, though his red cells at the time were the least resistant 
of the three, failed to develop jaundice; the other two did. 
The jaundice in the ligation experiment, however, lasted 
three days, and that of the control nine days. 

In the experiments with hemolytic immune serum the 
same results were obtained. In a preliminary experiment 

TABLE XLII 

Jaundice After Administration of ELemolttic Serum (Serum No. 3, 0.4 c.c. 

Per Kilo.) 



Time after 


Dog 4 Dog 2 

Vein switch Splenectomy 

(2 mos.) (2>3 mos.) 


Dog 25 
Normal control 


administration 


0.45 B. H. -0.325 C. H. 
Slight anaemia 


0.425 B. H.-0.25 C. H. 

Slight anaemia 


0.475 B. H.-0.35C. H. 

No anaemia 


Before 

1 day after 

2 days after 
4 days after 
6 days after 


Urine normal 
Xo bile 
Xo bile 
Xo bile 
Xo bile 


Urine normal 
Bile moderate 
Bile moderate 
Bile moderate 
Bile absent 


Urine normal 
Bile trace 
Bile moderate 
Bile absent 



with three animals, in which large doses of serum were 
given, the Eck fistula dog alone survived and developed 
jaundice; one with vein transplant and also a normal con- 
trol died in a few hours ; the control, however, had already 
developed hemoglobinuria, whereas the vein transplant 
dog failed to develop either hemoglobinuria or j aundice. 

With a weaker serum (see Table XLII) the greater 
resistance of the vein transplant, animal is shown. A result 



134 



THE SPLEEN AND ANAEMIA 



contrary to our former experiences was obtained in this 
experiment, in that No. 2 ( splenectomized ) developed as 
severe a jaundice as did the control. 

In another experiment (see Table XLIII) the same 
instructive results were obtained with a serum of less hasmo- 
lytic power. 

TABLE XLIII 

Jaundice After Administration of Hemolytic Serum (Serum No. 3, 0.2 c.c. 

Per Kilo.) 



Time after 
administration 


Dog 16 

Vein transplant 

(occluded vessels) 

(1 mo.) 


Dog 1 

Splenectomy 

(3 mos.) 


Dog 51 
Ligation 
(6 mos.) 


Dog 27 
Normal control 




0.4 B. H.- 

0.25 C. H. 

Ansemia present 


0.4 B. H.- 

0.25 C. H. 

Slight ansemia 


0.45 B. H.- 
0.325 C. H. 
No ansemia 


0.45 B. H- 
0.35 C. H. 

No anaemia 


Before 

1 day after 

2 days after 

3 days after 
5 days after 


Urine normal 
No bile 
No bile 
No bile 
No bile 


Urine normal 
No bile 
No bile 
No bile 
No bile 


Urine normal 
No bile 
Bile marked 
Bile marked 
Bile marked 
(Bile still pres- 
ent on the 
14th day) 


Urine normal 
Bile marked 
Bile moderate 
Bile trace 
Bile absent 



As the transplanted splenic vein of No. 16 was found 
at autopsy to have been occluded by a comparatively recent 
thrombus (probably antedating the administration of 
serum), this experiment must be regarded as analogous 
to a ligation experiment. The relatively slight tendency 
to jaundice in this animal as compared with No. 51 may 
be largely explained by the greater resistance of the red 
cells in the former animal. 

The results of these experiments, while somewhat dis- 
cordant, indicate that the mechanical factor of the method 
of the blood's approach to the liver is of importance in de- 
termining the degree of jaundice after the administration 



CONTROL EXPERIMENTS 135 

of haemolytic agents. Our results in this regard are in 
accord with those obtained in our comparative studies of 
the effect of injecting haemoglobin into the portal as con- 
trasted with the general circulation (see page 64). 

The interpretation of the severity and duration of the 
anaemia caused in the various test animals is complicated 
by several factors. In the first place, the original operation 
necessary to produce the venous anastomosis has been 
shown to cause anaemia. As the test animals were some- 
times given the haemolytic agent while more or less anaemic, 
we have had to analyze our results with constant reference 
to this factor. Moreover, we have found that in most cases 
the severity of the anaemia largely parallels the resistance 
of the red cells. In some cases, however, animals with the 
most fragile cells develop the least anaemia after adminis- 
tration of haemolytic agents. Changes in weight in the 
animals of these experiments seem to bear no definite 
significant relation to the anaemia. 

We have previously stated 22T that " the anaemia caused 
in splenectomized animals by haemolytic agents is, as shown 
by direct blood examination, of greater severity, runs a 
longer course, and has a longer period of repair." By 
greater severity was meant that the haemoglobin and red- 
cell count reached lower figures than in the control. The 
actual blood destruction, however (if determined by esti- 
mating the change from the condition immediately before 
administering haemolytic agents ) , was usually less in sple- 
nectomized than in normal dogs. Our experiments of this 
year show that the same statements hold true after trans- 
plantation of the splenic vein into the vena cava, Eck 
fistula, and ligation of the splenic veins. 

The actual blood destruction of the test animals has 



136 



THE SPLEEN AND ANEMIA 



been constantly less than in the normal controls, and in a 
few instances even the degree of ansemia as expressed by 
the haemoglobin and red-cell count was less severe in the 
test animals. As a constant feature, the greater severity 
of the anaemia must therefore be considered as open to 

TABLE XLIV 

Duration and Severity of Anaemia After Administration of Toluylene- 
diamin (0.34 Gm. Per Kilo.)* 



Time after 
administration 



Before 

1 day after 

3 days after 

5 days after 

7 days after 

9 days after 

12 days after 

16 days after 

22 days after 

29 days after 

35 days after 

41 days after 

49 days after 



Dog 71 
Splenic vein transplant 



Haemo- 
globin 



per cent. 

98 
102 
58 
68 
72 
83 
96 
98 
96 



Red blood 
cells 



6,785,000 
6,940,000 
5,490,000 
5,340,000 
4,820,000 
5,070,000 
5,890,000 
6,210,000 
6,350,000 



6,800,000 



Resistance 



B. H. C. H. 

0.45 -0.325 
0.5 -0.3 
0.475-0.275 
0.475-0.325 
0.475-0.325 
0.5 -0.3 
0.5 -0.3 

0.5 -0.3 

0.5 -0.3 
0.475-0.325 



Dog 79 

Splenectomy 



Hsemo- 
globin 



per cent. 

74 
84 
60 
43 
52 
63 
66 
69 
68 
76 



92 



Red blood 
cells 



5,720,000 
4,770,000 
4,250,000 
3,380,000 
3,820,000 
4,080,000 
4,320,000 
4,530,000 
4,510,000 
5,280,000 
5,590,000 
5,480,000 
5,680,000 



Resistance 



B. H. C. H. 

0.4 -0.275 
0.5 -0.275 
0.425-0.275 
0.45 -0.25 
0.45 -0.25 
0.425-0.25 
0.425-0.25 



0.4 
0.4 
0.4 
0.4 
0.4 



-0.275 

-0.25 

-0.275 

-0.35 

-0.25 



Time after 
administration 



Dog 51 

Ligation 



Hasmo- 
globin 



Before 

1 day after 

3 days after 

5 days after 

7 days after 

9 days after 

12 days after 

16 days after 

22 days after 

29 days after 

35 days after 

41 days after 

49 days after 



per cent. 

80 

90 

60 

62 
65 

72 
74 
76 
84 
78 
87 



Red blood 
cells 



4,920,000 
4,800,000 

3,820,000 

3,310,000 
3,980,000 
4,320,000 
4,650,000 
4,950,000 
5,330,000 
5,340,000 
5,550,000 



B. H. C. H. 
0.45 -0.275 
0.5 -0.325 

0.375-0.25 

0.45 -0.3 
0.45 -0.275 



0.475-0.35 

0.425-0.3 
0.45 -0.3 



Dog 75 
Normal control 



Haemo- 
globin 



per cent. 

85 
96 
48 
38 
45 
55 
68 
80 
85 



Red blood 
cells 



6,180,000 
5,080,000 
4,590,000 
2.980,000 
3,630,000 
3,930,000 
4,800,000 
5,200,000 
5,820,000 



Resistance 



B. H. C. H. 

0.425-0.275 

0.45 -0.35 

0.475-0.275 

0.45 -0.3 

0.475-0.3 

0.45 -0.3 

0.475-0.3 

0.475-0.3 

0.425-0.3 



♦The figures in the columns "Resistance" indicate the percentages of salt solution at 
which haemolysis was first noticed and first became complete. 



CONTROL EXPERIMENTS 



137 



question, while the actual blood destruction in the test ani- 
mals is undoubtedly less than in the normal controls. 

The duration of the anaemia of the test animals has 
been longer than that of the normal controls and paralleled 
that of the splenectomy controls. The difference, how- 
ever, of both test and splenectomy dogs from the normal 
controls has been less striking than in our previous work, 
and, like the variable degree of anaemia after splenectomy, 
must be referred to variations in unknown factors (pos- 
sibly such as diet, or differences in toxicity of the serum). 

An experiment with toluylenediamine showing the char- 
acter of the blood repair after various forms of experi- 
mental disturbance of splenic function is seen in Table 
XLIV. 

TABLE XLV 



Duration and Severity of Anaemia After Administration of ] 
Serum (0.4 cc. Per Kilo.) 


HEMOLYTIC 


Time after 


Dog 4 

Vein transplant 

(2 mos.) 


Dog 2 

Splenectomy 
(3H mos.) 


Dog 25 
Normal control 




Haemo- 
globin 


Red blood 
cells 


Haemo- 
globin 


Red blood 
cells 


Haemo- 
globin 


Red blood 
cells 


Before 
1 day after 
6 days after 
10 days after 
16 days after 
19 days after 
26 days after 
31 days after 


per cent. 

97 
83 
65 
62 
70 
90 
96 
102 


6,960,000 
4,840,000 
3,940,000 
3,750,000 
4,390,000 
5,060,000 
6,010,000 
6,400,000 


per cent. 

85 
78 
55 
67 
67 

78 
82 


4,950,000 
4,920,000 
3,670,000 
3,890,000 
4,090,000 

5,260,000 
5,590,000 


per cent. 

102 
82 
58 
78 
80 
93 

106 


6,400,000 
5,040,000 
3,950,000 
4,480,000 
4,880,000 
5,490,000 
6,060,000 



In a second experiment the red cells of an Eck fistula 
animal dropped one million less than the control, but took 
two months to return to normal level, as opposed to nine- 
teen days in the control. In a third experiment smaller 
doses of serum failed materially to affect the blood picture. 

A similar experiment with hemolytic immune serum 
is presented in Table XLV. 



138 THE SPLEEN AND ANEMIA 

In another experiment a weaker serum failed to cause 
anaemia in a splenectomized dog, as well as in one with 
occluded splenic vein transplant; however, an animal with 
ligated splenic vein developed about the same amount of 
anaemia as the control, but took a much longer time to 
recover. 

Behavior of Leucocytes. — Bothtoluylenediamine and 
hemolytic immune serum cause a marked leucocytosis, 
which reaches its height in one to three days and lasts 
two to four weeks. The first and greatest rise ( actual and 
relative ) is in the polymorphonuclear and transitional cells ; 
this is later followed by a less marked and more persistent 
rise of small lymphocytes and eosinophiles. There was 
no essential difference in the reaction of the test dogs 
and their controls, except that the latter were affected 
by doses too small to influence the former. These changes 
resemble those previously described as following the vari- 
ous operative procedures on the spleen, and probably indi- 
cate a general rather than any specific interference with 
the leucocytic elements of the blood. 

From these observations the following tentative con- 
clusions may be drawn: 

1. Dogs whose splenic vein or portal vein (Eck fistula) 
has been transplanted into the inferior vena cava, or whose 
splenic veins have been ligated, develop a lessened tendency 
to jaundice similar to that exhibited by splenectomized 
animals. 

2. Although the previously existing anaemia and the 
concomitant increased resistance of the red cells of these 
animals are undoubtedly factors in the greater resistance 
to hsemolytic agents, the lessened tendency to jaundice is, 
in part at least, due to a mechanical factor dependent on 
the change in the blood supply to the liver. 



CONTROL EXPERIMENTS 139 

3. The additional anaemia caused in the test animals by 
hemolytic agents is usually less than in the controls, al- 
though the total fall from the original normal may be, 
and usually is, greater than in the control. This applies 
to the splenectomized as well as the other test animals of 
these experiments. 

4. Although the destruction of blood in these animals is 
less than in the controls, the repair of the same takes con- 
siderably longer than in the controls. This confirms sim- 
ilar results previously obtained in splenectomized animals. 

5. The white cells exhibit much the same changes as 
follow the administration of hemolytic agents to splenecto- 
mized or normal animals. As these changes are not unlike 
those following uncomplicated splenectomy or the opera- 
tions here discussed, they cannot be considered as char- 
acteristic of any of the above procedures. 



CHAPTER VI 

THE CHANGES IN THE BONE-MARROW AFTER 
SPLENECTOMY 

(i) DISCUSSION OF THE LITERATURE, (2) HISTO- 
LOGICAL STUDIES OF THE DOG'S NORMAL MAR- 
ROW, (3) CHANGES AFTER SPLENECTOMY 

In many instances we have examined 340 the bone- 
marrow of splenectomized dogs with a view to determining 
the compensatory or other changes following the removal 
of the spleen. The material at our disposal consists of 
marrows representing periods varying from a few days to 
twenty-two months after splenectomy. 

In the literature of the subject the reference to changes 
in the bone-marrow following splenectomy are for the most 
part casual and presented but incidentally in connection 
with the associated changes in the lymph- and haemolymph- 
glands. In Warthin's 461 collection of the literature up to 
1903 the following references occur: 

Tizzoni and Fileti 439 (1880) and Tizzoni 438 (1882) 
observed in splenectomized dogs a transformation of the 
fatty marrow of long bones into red marrow. 

Mosler 303 (1882), working likewise with dogs, con- 
cluded that, following splenectomy, there may be com- 
pensatory action on the part of both lymph-glands and 
bone-marrow, the latter appearing to play an important 
role. In one animal the bone-marrow, ten months after 
splenectomy, resembled that of leukaemia. This change, 
however, was not constant. 

Laudenbach 240 (1893) observed in one dog, ten to 

140 



CHANGES IN BONE-MARROW 141 

twelve years of age, with severe anaemia, signs of increased 
blood formation in the marrow 14,5 days after splenectomy. 

Ceresole Gi) (1895), on the other hand, found in sple- 
nectomized rabbits no clearly defined new formation of the 
marrow. 

Warthin 461 ((1903) states that after splenectomy in 
the sheep and goat slight lymphoid changes in the fatty 
marrow occur, but gives no detailed histological descrip- 
tion. Of these changes he says: " The beginning lym- 
phoid changes in the fatty bone-marrow in the second and 
fifth months after splenectomy is to be regarded as com- 
pensatory only for the increased destruction of red blood- 
cells and not for any abrogated splenic function of red-cell 
formation." 

Other references may be found to changes in the bone- 
marrow in the presence of diseases of the spleen in man and 
in experimental anaemias of animals with or without sple- 
nectomy, but few findings after simple removal of the 
normal spleen are available. Among the latter are Pug- 
liese's 363 observation that after total splenectomy the bone- 
marrow of the hedgehog becomes filled with giant-cells. 
This change Foa 119 has not found to be characteristic of 
the rabbit. Vulpius, 460 who, in 1894, reviewed thoroughly 
the subject of the surgery and physiology of the spleen, 
and adds some experimental observations, supports the 
theory of increased activity of the bone-marrow after sple- 
nectomy. Winogradow 475 found red marrow in the long 
bones of a dog 132 days after splenectomy, but yellow 
marrow was present in two after 517 and 760 days respec- 
tively, though one of the latter was slightly streaked 
with red. 

Hodenpyl, 181 in the description of a case of absence 



142 THE SPLEEN AND ANAEMIA 

of the spleen in man makes no mention of the bone-marrow. 

Taylor 429 describes the marrow of two splenectomized 
dogs : that from an animal receiving albumoses by mouth 
and by hypodermic in j ection, and killed after nine months, 
was red ; a second, not receiving albumoses, showed a yellow 
marrow at the end of one year. 

Freiberg 127a states that he found red marrow in sple- 
nectomized animals, and Gibson 140 notes that in a dog 
killed five and a half months after being deprived of the 
spleen the marrow was apparently in the process of change 
from yellow to red. 

In some of these accounts brief mention is made of the 
increase of giant-cells or of pigmented cells or of the 
numerical relations between the myelocytes and the white 
and red cells, but we have been unable to find an adequate 
account of the histology of the bone-marrow after splenec- 
tomy based on modern conceptions of the cytology of this 
tissue. Histologic descriptions exist, but they are either 
brief and fragmentary or are based on views current before 
the attainment of our present detailed knowledge of the 
morphology of the cells of the blood. 

Methods. — Our studies are based chiefly on the changes 
in the marrow of the long bones, and particularly in that 
of the femur. As this marrow in the adult is normally 
fatty, objection may be raised against its use, and to over- 
come this objection we attempted to study the marrow of 
the compact bones. The methods of decalcifying tissues 
have, however, in our hands failed to yield satisfactory 
histologic preparations. The alternative, the use of film 
preparations, obtained successively at intervals over long 
periods of observations, being impracticable, the study of 
cover-glass preparations was limited to a single observation 



CHANGES IN BONE-MARROW 143 

at the time of the death of the animal. At the same time, 
however, in many instances marrow squeezed from the 
ribs has been obtained in sufficient amount to section and 
thus to allow a comparison with changes in the fatty mar- 
row. We have, however, depended largely upon the study 
of sections of the marrow of the long bones, and in par- 
ticular of the femur. We are satisfied, as the result of our 
study of the marrow from a large number of normal dogs, 
that this is, after all, the most rational method of studying 
compensatory changes, for it is unusual, even in a definitely 
fatty marrow, not to find numerous centres of blood-form- 
ing cells. These may be limited to the periphery of the 
marrow or be scattered throughout, but, whatever their 
position, they afford an excellent starting-point for the 
study of increased cellular content, as well as of changes 
in the character of the cells. The fatty marrow is of 
especial value in the study of the late changes, for in well- 
fixed and well-stained marrow there can be no doubt about 
the change from a purely fatty marrow to a red marrow 
rich in cells. This is so striking as to remove all the doubt 
which exists when one examines the marrow of compact 
bone, as of the ribs or vertebrae, by either the section or 
cover-glass method. 

We have worked exclusively with the marrow of the 
middle third of the femur, avoiding the marrow at either 
end, partly on account of its bony nature, but chiefly be- 
cause of the occasional normal occurrence of more or less 
red marrow at the ends of the shaft. As only adult dogs 
have been used, we feel that the constant use of the middle 
portion of the marrow gives fairly comparable results. 
In removing the marrow half the circumference of the 
bone through the greater part of its length has been chipped 



144 THE SPLEEN AND ANAEMIA 

away, and after separating the marrow from the bone and 
cutting it at either end it has been easily removed as a solid 
cylinder by gently rolling it on to a piece of filter-paper. 
In carrying these tissues through the process of fixation 
and imbedding, the filter-paper, which is firmly adherent 
to the marrow through the coagulation of the attached 
blood, allows the necessary manipulations without injury 
to the marrow itself. The routine procedure has been to 
fix in Zenker's fluid without previous decalcification, imbed 
in paraffine, and stain with eosin and polychrome methylene 
blue. Other stains have, however, been used whenever 
necessary to bring out certain details. 

Results. — It may be stated at the outset that we have 
found no evidence of an early change in the bone-marrow. 
Splenectomy does not cause, as do successive hemorrhages 
and hemolytic poisons, a rapid change of fatty marrow 
to red marrow. This latter change we have produced read- 
ily and rapidly in non-splenectomized control animals by 
the use of specific hsemolytic serum and by causing hemor- 
rhage, but we have never seen a frank change from yellow 
to completely red marrow in the ordinary course of events 
in the splenectomized animal until many months, usually 
six or more, had elapsed, and this despite the fact that 
many of the animals have had, as has been shown in our 
earlier work, a moderately severe anaemia. This ansemia 
has frequently been of as severe degree as that caused by 
several successive hemorrhages in the normal dog, but 
changes in the marrow analogous to those caused by hemor- 
rhage have not been evident in the earlier periods following 
splenectomy. 

In this connection it may be recalled that the anaemia 
of splenectomy in the dog follows a gradual downward 



CHANGES IN BONE-MARROW 145 

course for three to six weeks, the decrease in haemoglobin 
being relatively more marked than the decrease in red cells, 
and that an equally gradual repair causes the red-cell 
count and haemoglobin content to approach normal after 
three to four months or more. At the same time there is 
a transient initial leucocytosis, due chiefly to polymor- 
phonuclear leucocytes, and sometimes lymphocytosis with 
a late eosinophilia. Not infrequently the eosinophiles dis- 
appear from the circulating blood from the third week until 
the end of the third month. 

We have, therefore, in the course of our studies at- 
tempted to determine whether the hyperplasia in the bone- 
marrow after splenectomy is compensatory in the sense of 
( 1 ) an overactivity in red-cell formation chiefly, ( 2 ) over- 
activity in the formation of the white cells chiefly, (3) an 
overactive, orderly reproduction of a new marrow, with 
involvement of all cells arising within it. 

The Normal Marrow of the Femur or the Dog 
In our study of the marrow of both normal and sple- 
nectomized animals we have used as a basis for orientation 
Bunting's 63 conception of erythrogenetic and leucogenetic 
centres, Muir's 306 descriptions of erythroblastic and leuco- 
blastic reactions, and have received also much aid from 
Dickson's 93 study of the cytology of marrow. The ar- 
rangement described by Bunting is by no means a constant 
and definite one, but in the masses of marrow cells may 
be seen groups composed mainly of myeloblasts and sur- 
rounded at times by a nearer zone of myelocytes and an 
outer zone of leucocytes; in other groups with the same 
centre the outer zone may be made up of nucleated red 

cells, with a still more distant zone of normocytes. We 
10 



146 THE SPLEEN AND ANEMIA 

are not convinced that centres for the production exclu- 
sively of red cells or of white cells exist, for frequently an 
intermingling of the two types is seen in one centre, but 
this conception of definite centres is of great assistance 
in the interpretation of marrow changes. 

The study of the marrow of the femur from many 
normal dogs has led to our recognition of four definite 
groups of cells: 

1. Groups of undifferentiated cells and myelocytes. 
These lie between fat cells and seem to be in no way con- 
nected with blood-channels. In all these centres the cells 
of the connective-tissue reticulum are in evidence. 

2. Groups of the character described above, but with a 
peripheral accumulation of cells in which those of the leu- 
cocytic series predominate. 

3. Groups as in ( 1 ) , but with a mantle of cells in which 
those of the erythrocytic series are most in evidence; and 

4. Groups as in (1), but with an indiscriminate min- 
gling of cells of red and white series. 

These groups cannot always be differentiated, for not 
infrequently an indiscriminate mingling of cells obscures 
the recognition of centres. Moreover, at times may be 
seen groups composed purely of white cells or of red cells 
without myeloblasts centres. We have, however, found 
that search for the groupings described greatly facilitates 
the study of complex marrow pictures and leads readily to 
a decision as to whether leucoblastic or erythroblastic activ- 
ity predominates. 

In one respect the study of normal marrow has not 
helped us greatly. Megakaryocytes and polykaryocytes 
are so infrequent in the normal fatty marrow that we have 
no basis, in regard to them, for a comparison with hyper- 



CHANGES IN BONE-MABROW 



147 



plastic marrow. The same holds true for the large en- 
dothelial cells which are phagocytic for red cells and are 
found so frequently in hyperplastic marrow to contain 
remnants of red cells and particles of pigment. 

The Marrow of Splenectomized Animals 

In Table XL VI the general results of our observations 
are presented. The terms " yellow " and " red " refer to 
the gross appearance, not of the surface of the marrow, 

TABLE XLVI 
Hyperplasia op the Marrow of the Femur After Splenectomy 











Blood picture shortly 


Dog 


Period after 


Gross 


Microscopic 


before autopsy 


No. 


splenectomy 






Haemoglobin 


R. B. C. 


50 


24 days 


Yellow 


Slight 


88 


4,510,000 


23 


39 days 


Yellow 


None 


88 


6,050,000 


21 


40 days 


Yellow 


Slight 


65 


2,970,000 


86 


42 days 


Yellow 


Slight 


96 


5,820,000 


79 


60 days 


Yellow 


Slight 


92 


5,680,000 


82 


63 days 


Slight streaking 


Slight 


76 


4,530,000 


17 


84 days 


Yellow 


Slight 


56 


3,850,000 


10 


6 months 


Red 


Complete 


78 


4,410,000 


39 


7 months 


Red 


Complete 


68 


4,040,000 


32 


8 months 


Yellow 


Slight 


97 


6,120,000 


44 


9 ^months 


Yellow 


None 


81 


4,970,000 


41 


10 months 


Yellow 


None 


92 


4,920,000 


24 


1 year 


Red 


Complete 


110 


6,048,000 


59 


1 V2 years 


Red 


Complete 


101 


5,100,000 


57 


1 X A years 


Streaked 


Partial 


110 


5,206,000 


33 


1^4 years 


Red 


Almost complete 


70 


4,480,000 


51 


If years 


Yellow 


Slight 


110 


6,200,000 



but of the cross-section. " Slight streaking " and 
" streaked " refer to an intermingling of yellow and red 
marrow. A marrow is described as " red " only when it 
is uniformly so. As will be seen by a comparison of gross 
and microscopic appearances, a marrow " yellow " to the 
naked eye may, microscopically, show evidence of begin- 
ning hyperplasia. The early changes are indicated by the 



148 THE SPLEEN AND ANiEMIA 

word " slight." The word " complete " indicates that only 
an occasional fat cell is seen microscopically. " Almost 
complete " means that fat cells occupy less than one-tenth 
of the marrow space in the surface area of sections studied. 
Several purely fatty marrows representing periods be- 
tween five and twenty-four days after splenectomy are 
not included in the table. 

The bone-marrows representing the earlier periods of 
splenectomy, in that they show practically no changes, may 
be dismissed briefly. This is true of a series from animals 
killed at various intervals from five days to three months. 
Some of these marrows cannot be distinguished from those 
of the normal dog. In others, slight replacement of fatty 
tissue is seen. Thus one representing the twenty-fourth 
day shows here and there between the fat cells single rows 
of blood-forming cells, with now and then clumps of ten 
to thirty or more. These areas are neither purely erythro- 
genetic nor purely leucogenetic, though in some of the 
groups with an older type of cells there is a predominance 
of polynucleated cells. Tne endothelial cells of the reticu- 
lum not infrequently contain large masses of old blood- 
pigment. 

Another, representing the fortieth day, presents prac- 
tically the same appearance, with a tendency, however, to 
greater erythrogenesis. On the other Hand, a thirty-nine 
day dog shows a simple fatty marrow with no evidence of 
active blood formation. Three other marrows of this 
period, however, show already the early stages of hyper- 
plasia; both types of cell groups can occasionally be iso- 
lated, but usually the groups are mixed. Greater numbers 
of eosinophile cells, both myelocytic and polymorphonu- 
clear, are present than have been evident in earlier periods. 



CHANGES IN BONE-MARROW 149 

A number of cells throughout the section correspond to 
Longcope's 2r>4 small lymphocytes, and a smaller number 
to Longcope's large lymphocytes. The small lympho- 
cytes are not, however, in pure groups. Polymorphonu- 
clear leucocytes are abundant, and the picture, as a whole, 
is one of leucogenesis rather than of erythrogenesis. Very 
few giant-cells are seen, and only occasional phagocytes. 

In another marrow of the sixty-third day a moderate 
peripheral hyperplasia of mixed type is present. Marked 
congestion is evident between the fat cells, and hyper- 
plasia is seen, in places, near the periphery; in some in- 
stances the erythrocytes appear to be outside the vessel, 
forming distinct areas of hemorrhage. A few phagocytes 
are present, but giant-cells are rare. Polymorphonuclears 
are frequent and of mature development. At the periphery 
erythrogenesis seems to predominate over leucogenesis. 
Eosinophils and lymphoid cells are not conspicuous. 

A marrow of the sixtieth day shows less hyperplasia, 
but leucocytic reaction is more evident, though erythro- 
genesis is active. Scattered throughout the section are 
many small lymphocytes, but nowhere are these seen in 
solid clumps. Numerous deposits of pigment are seen. 

Again, on the eighty-fourth day, an essentially fatty 
marrow shows a narrow cellular strip at the periphery in 
which erythrogenesis is quite active. Here and there 
leucogenesis predominates, but in the main the process is 
erythrogenetic. A few nucleated red cells of the megalo- 
blastic type are found, but the more mature normoblasts 
are more abundant. In some centres radiating lines of 
four or five normoblasts are seen. Few giant-cells are 
present. 

The marrows of the fourth and fifth months after 



150 THE SPLEEN AND ANAEMIA 

splenectomy are not represented in this study. Well- 
marked hyperplasia is, however, present in bone-marrow 
representing periods of six, seven, twelve, seventeen, 
eighteen, and twenty months after splenectomy. On the 
other hand, two marrows representing respectively nine and 
one-half and ten months show no departure from the nor- 
mal fatty marrow, and in a third (eighth month) only 
slight hyperplasia is evident. In the latter are areas com- 
posed almost entirely of cells of the myelocyte or pre- 
myelocyte type, with some evidence of the formation of 
both red cells and polymorphonuclear leucocytes. The 
picture suggests a proliferation of the primitive cells of 
the marrow, without, however, a very active further differ- 
entiation. In a fourth animal of the late period (twenty- 
second month) only slight hyperplasia was present. With 
evidence of well-marked hyperplasia in other animals at 
six and seven months after splenectomy and after a year 
and a half, it is impossible to explain its failure in these 
four animals representing the eighth, ninth, tenth, and 
twenty-second months respectively. 

The best opportunity of studying the late changes is 
presented by material from six animals, representing the 
period from six to twenty months, in all of which the 
fatty marrow of the femur was transformed entirely or 
in large part into red marrow. The histological picture of 
each of these will be given in detail. 

Dog 10. — Splenectomized May 20, 1913. Before oper- 
ation the red cells numbered 6,910,000 and the haemoglobin 
was 105 per cent. The severest anaemia was reached July 
21: red cells 4,240,000, haemoglobin 62. On September 
11th the figures were 5,220,000 and 92. Later the animal 
became pregnant and anaemia recurred, the picture on No- 






CHANGES IN BONE-MARROW 151 

vember 18 being red cells 4,410,000, haemoglobin 78 per 
cent. On November 24 the animal was chloroformed. At 
autopsy the medulla of both femurs presented a deep-red 
marrow. 

Histologically is seen a uniformly cellular tissue, with 
only occasionally a fat space here and there at the pe- 
riphery. For the most part this marrow is as definitely 
cellular as is, for example, a lymph-node or the spleen, and 
indeed, it has much of the appearance of the pulp of the 
latter organ in the new-born puppy. In this cellular mass, 
which at first appears to present a hopeless confusion of 
cells, it is not difficult to resolve the cells into more or less 
distinct proliferating centres. The arrangement is by no 
means a definite one, but in the patchwork of cells one 
sees groups which correspond to Bunting's description. In 
speaking of these centres we will refer to them as erythro- 
genetic or leucogenetic, according to whether red cells or 
polymorphonuclear leucocytes predominate in the mass of 
cells surrounding the centre in question. We have made 
no attempt to distinguish in these centres, which may in- 
clude from six to thirty cells, between the finely granular 
neutrophilic myelocyte and the non-granular basophilic 
cell from which it is supposed to arise. In these centres 
mitotic figures may occasionally be seen, but only after 
prolonged search. It is also in these centres that old 
blood-pigment, which is quite abundant in this marrow, 
is deposited; its deposition in the loose vascular tissue 
elsewhere has not been observed. The erythrogenetic 
centres appear to be more active than the leucogenetic. 
This impression is based on the fact that about a mass of 
myeloblasts, composed of twelve to fifteen cells, may be 
seen twenty-five to thirty nucleated red cells and a small 



152 THE SPLEEN AND ANAEMIA 

number of normocytes, while about the leucogenetic centres 
comparatively few leucocytes are seen. The red cells in 
question vary in size and show intermediate stages from 
the megaloblast to the normocyte. It is not to be supposed 
that about erythrogenetic centres no leucocytes occur; a 
few are always present. For example, among the twenty- 
five to thirty cells mentioned above, eight polymorphonu- 
clear leucocytes could be clearly distinguished. Sometimes 
on one side of a centre nucleated erythrocytes may be 
grouped, and on the other leucocytes, with little inter- 
mingling. This suggests simultaneous formation of the 
two cells in one cell centre. When this occurs the number 
of red cells is always greater than the number of leuco- 
cytes, in proportion of about 4 to 1. All through the 
section are lymphoid cells, usually single and of the small 
variety. Giant-cells are frequent, and a few show inclu- 
sions of polymorphonuclear leucocytes. Cells containing 
such inclusions have a broad, homogeneous gray staining 
protoplasm suggesting necrosis. There is considerable 
pigment, but not many phagocytic endothelial cells are 
seen. Normoblasts are seen free in the capillaries. Smears 
from the marrow of the ribs show active erythrogenesis 
and, on the whole, much the same cellular picture as the 
marrow just described. In the rib-marrow a considerable 
number of eosinophiles, chiefly polymorphonuclears, are 
also seen. In connection with the activity in the formation 
of red cells shown by the marrow, it is significant that the 
blood count six days before death was 4,100,000 and the 
haemoglobin 78 per cent, (on September 11, four months 
after splenectomy, the figures were 5,240,000 and 92). 
In other words, despite the hyperplasia of the bone-mar- 
row, the animal exhibited a late anaemia, two and a half 



CHANGES IN BONE-MARROW 153 

months after recovery from the initial anaemia, following 
splenectomy. This may have been due to the drain occa- 
sioned by the intervening pregnancy — an unfortunate 
complication from the point of view of the study of the 
blood. The fact remains, however, that the marrow is 
actively forming normal red cells. The anaemia was, there- 
fore, not due to abnormally low erythrogenesis in the 
marrow. 

Dog 39. — On April 7, 1913, before splenectomy, the 
red cells numbered 6,528,000, and haemoglobin was 110 
per cent. The lowest point of anaemia was reached on 
June 3, the red cells numbering at that time 3,650,000 ; the 
haemoglobin was 62 per cent. By July 7 the blood picture 
had improved (red cells 5,080,000, haemoglobin 88 per 
cent.), but on September 11 a late recrudescence of the 
anaemia gave red cells 4,040,000 and haemoglobin 68 per 
cent. The animal was killed on November 15. The bone- 
marrow of the femur was of a definite red color. The 
anaemia did not affect the general nutrition of the animal, 
for on April 7 the weight was 12,800 gms.; on November 
15 it was 13,950, and the adipose tissue was abundant. 

This animal, representing practically the same period 
after splenectomy and the same changes in the blood as 
Dog 10, gives very much the same picture in the marrow. 
Of minor importance is the fact that the marrow is not 
so cellular, the proportion of cells to fat being in the ratio 
of about 3 to 2; also, the myelocytic centres are not so 
pronounced, but in other respects the marrow is the same. 
Many giant-cells are present, but lymphoid cells are rare. 
The formation of red cells and leucocytes is perhaps not 
so rapid (that is, the numbers about any one centre are not 
so great), but, on the other hand, the erythrogenetic 



154 THE SPLEEN AND ANAEMIA 

activity of the marrow is sufficient to exclude the possi- 
bility of an inactive bone-marrow being responsible for the 
late recrudescence of anaemia. 

Dog 24* — This animal was splenectomized on Febru- 
ary 10, 1912, and was used for the injection of haemolytic 
immune serum on March 20 and again on April 7. On 
June 28 it had recovered from the anaemia then produced 
(red cells 5,650,000, haemoglobin 89 per cent.), and on 
July 15 it was treated with sodium oleate. On Septem- 
ber 26 the red-cell count was 5,780,000 and haemoglobin 
90 per cent. On February 19, 1913, the blood picture 
had improved (red cells 6,048,000, haemoglobin 110 per 
cent. ) , and at this time haemolytic serum was again injected. 
The animal was chloroformed on March 4, 1913. The lapse 
of time since splenectomy was, therefore, thirteen months. 
At autopsy a red marrow was found. 

Owing to the use of various haemolytic poisons, the 
bone-marrow of this animal may have been influenced by 
other factors than the absence of the spleen. The his- 
tological picture, however, is so in accord with the marrow 
of simple splenectomy that, with this explanation, it is 
included in the series. 

Histology. — The marrow is a uniformly solid marrow, 
with no fat spaces visible in any of the sections examined. 
It does not, however, appear to be as cellular as the marrow 
of Dogs 10 and 39. This difference is caused by a greater 
congestion and distention of the blood-vessels, a slight in- 
crease in the reticulum, and a lessened tendency of the 
myelocytic tissue to be grouped in large centres. Ery- 
throblastic centres are very prominent and very active: 
leucogenetic centres, on the other hand, are made out with 
difficulty. Lymphoid elements are rare. Many cells of 



CHANGES IN BONE-MARROW 155 

the myelocytic type are seen with coarse basic granules 
and short threads in the nucleus and with little or no 
protoplasm. In close relation to these are sometimes seen 
degenerated mitotic cells, but whether all the chromatin 
masses can be so interpreted is not clear. These degenera- 
tive changes are doubtless the result of the last injection of 
hemolytic serum. 

Dog 59. — On July 24, 1912, this animal was splenec- 
tomized and used for the study of the progressive anaemia 
following this procedure. On December 7, 1912, the 
highest point (red cells 5,250,000, haemoglobin 105 per 
cent.) of recovery was reached. Continued observation 
showed a slight decline to 5,2;00,000 red cells and 86 per 
cent, of haemoglobin on May 21, 1913, on which date the 
animal was used in an experiment with sodium oleate. 
From the moderate anaemia caused at this time the animal 
recovered, the blood examination on June 9 showing 5,050,- 
000 red cells and 86 per cent, haemoglobin, the condition 
slightly improving as to haemoglobin content until Novem- 
ber 18, 1913, when red cells were 5,100,000 and haemoglobin 
101 per cent. The animal was chloroformed on Novem- 
ber 24. At autopsy the bone-marrow of the femur was 
soft, succulent, and dark red in color. In connection with 
the general condition of this animal it is of interest to 
note that in the last seven months its weight increased 
from 10,450 grammes to 12,580 grammes, and that adipose 
tissue was very abundant. The administration of sodium 
oleate introduces a possible disturbing factor, but as this 
was given six months before death, and as the anaemia 
which it caused was quickly repaired, it is not considered, 
in view of our other observations, to have had an important 
influence on the bone-marrow. 



156 THE SPLEEN AND ANAEMIA 

Histology. — The marrow shows some fat cells, the 
proportion of marrow cells to fat being about 10 to 1. 
Nothing different from the last four marrows is pre- 
sented. Leucogenesis and erythrogenesis proceed at about 
equal rate, the latter being a little more active. Mitotic 
figures are seen not infrequently, but the type of cell in 
which they occur is not always evident. Myeloblasts seem 
to be more abundant than usual. Giant-cells are fairly 
abundant, but lymphoid cells are rare. 

Dog 57.— On June 23, 1912, the blood of this dog con- 
tained 5,350,000 red cells per cubic millimetre and 98 per 
cent, haemoglobin. On July 2 the spleen was removed. 
The resulting anaemia reached its lowest point (red cells 
2,970,000, haemoglobin 50 per cent. ) , on August 5. On 
October 24, when the blood count showed 5,240,000 red 
cells and 90 per cent, haemoglobin, the animal received 
sodium oleate intravenously ; a slight anaemia ( fall in haemo- 
globin to 62 per cent., but no marked change in red cells) 
resulted. In January, 1913, the red cells were 5,206,000, 
haemoglobin 110 per cent., and with slight variations this 
higher level was maintained, accompanied by an increase 
in body weight, until December 12, 1913, when the animal 
was chloroformed. At autopsy the animal was found to 
have a large amount of adipose tissue; the bone-marrow of 
the femur was definitely reddish in color, with faint yellow- 
ish streaks. As the sodium oleate given four months after 
splenectomy and fourteen months before death produced 
only a slight transient change, we consider that the bone- 
marrow represents the effect of splenectomy only. 

Histological Examination. — The relation of the fat 
to cells is about 1 to 1 ; otherwise nothing new is seen. The 
marrow is very active, leucogenesis and erythrogenesis 



CHANGES IN BONE-MARROW 157 

being equally prominent. Phagocytic cells and masses of 
old blood-pigment are quite numerous, as are also giant- 
cells. More abundant than in other marrows are eosino- 
phils of the myelocytic type. Lymphoid cells are not 
conspicuous. 

Dog S3. — This animal was splenectomized on May 14, 
1912. The blood examination on the previous day showed 
4,950,000 red cells and 85 per cent, haemoglobin. The 
anaemia following splenectomy reached its lowest point on 
June 28 (red cells 3,550,000, haemoglobin 52 per cent.). 
On September 20 the red cells had risen to 5,490,000 and 
haemoglobin to 95 per cent. In November, 1913, the 
animal passed successfully through pregnancy. In Janu- 
ary, 1914, as the animal had developed mange, it was 
chloroformed. The blood examination on the preceding 
day was red cells 4,480,000, haemoglobin 70 per cent. At 
autopsy the bone-marrow of the femur was deep red in 
color. (It should be stated that one and two months 
before splenectomy the animal had received injections of 
haemolytic serum. From our studies of the effect of haemo- 
lytic serum in the normal dog, we do not believe that these 
injections, several weeks before splenectomy and nearly 
two years before death, are in any way responsible for 
the hyperplasia of the marrow.) 

Histological Examination. — This marrow differs in 
no way from the marrows of Dogs 57 and 59 described 
above. 

Dog 51. — The spleen was removed on May 31, 1912, 
and on June 26 of the same year haemolytic serum was 
administered. From the anaemia thus produced the animal 
made a slow recovery, but after 200 days the blood examin- 
ation showed 6,200,000 red cells and 110 per cent, haemo- 



158 THE SPLEEN AND ANEMIA 

globin, as compared with 6,210,000 red cells and 100 per 
cent, haemoglobin before splenectomy. On March 26, 1914, 
when the animal was chloroformed, its weight was 9750 
grammes, as compared with 8270 grammes at the time of 
splenectomy and 8120 grammes when haemolytic serum 
was administered. The notes made at the autopsy refer 
to the large amount of adipose tissue, the normal appear- 
ance of the lymph-nodes, the absence of supernumerary 
spleens, and the presence in the long bones of a distinctly 
yellow, fatty marrow. Histological examination of the 
marrow shows a very slight hyperplasia, with large num- 
bers of leucocytes and deposits of blood-pigment. 

Discussion. — It will be remembered that in discussing 
the anaemia which follows splenectomy it was pointed out 
that nucleated and other abnormal forms of red cells are 
rarely found in the circulating blood, and that when they 
do occur they do not persist for any length of time. Appar- 
ently their appearance corresponds to the beginning repair 
and not to the period of hyperplasia of the marrow which 
we have described. It is difficult, therefore, to bring the 
changes in the bone-marrow into relation with the changes 
in the peripheral blood. If the hyperplasia of the bone- 
marrow is compensatory to increased blood destruction or 
decreased blood formation, one would expect definite 
hyperplasia to be present in the earlier period, during the 
first three months after splenectomy, at a time when the 
anaemia is evident and repair is taking place, and not after 
six months to a year or a year and a half, when the blood 
picture is normal. It is true that in two of the animals 
(Dogs 10 and 39) a late recrudescence of anaemia occurred 
and the marrows of these animals were obtained during 
this period, but this was not the case in most of the animals 



CHANGES IN BONE-MARROW 159 

of the series and is not characteristic of the late periods 
after splenectomy. It is therefore impossible, on account 
of the late development of hyperplasia in the marrow, to 
explain its occurrence as compensatory to the anaemia fol- 
lowing splenectomy. 

Likewise we cannot accept Warthin's 401 theory based 
upon his study of sheep and goats. In these animals 
Warthin found hyperplasia of the marrow to occur several 
months after splenectomy and to be associated with evi- 
dence of increased destruction of red blood-cells in the 
lymph- and haemolymph-nodes. This destruction, greater 
than that in the primitive spleen, is responsible, he be- 
lieves, for the anaemia following splenectomy, and this is 
in turn compensated by increased activity in the bone- 
marrow. We have found little to support this theory in 
our studies of the dog. The lymph-nodes, as well as the 
endothelial cells of the liver, as we have shown elsewhere, 333 
are indeed more active in the phagocytosis and destruction 
of red cells after splenectomy than in the normal animal, 
and this is very evident when large numbers of red cells 
are injured, as by the administration of a hemolytic poi- 
son ; but in the ordinary course of events, after splenectomy, 
the lymph-nodes present no evidence of excessive blood 
destruction. An occasional cell containing one or two red 
cells may be seen, and small amounts of old blood-pigment 
are occasionally demonstrable, but of excessive haemolysis 
there is no evidence. Likewise, microchemical tests for 
iron in the lymph-nodes and liver show that little differ- 
ence exists in this respect between the normal and splenec- 
tomized animals. For this reason, and because the anaemia 
is not persistent and progressive, w T e cannot support the 
theory that the hyperplasia of the marrow is compen- 



160 THE SPLEEN AND ANEMIA 

satory to abnormal blood destruction in the lymph-nodes. 

Another possible explanation is that the bone-marrow, 
in the absence of the spleen, is concerned in the storing 
and utilization of iron. There is no doubt that, in the 
normal animal, iron set free in the dissolution of red cells 
is stored in the spleen. After splenectomy a readjust- 
ment in the storage of iron takes place, and there is some 
evidence that for a short time after the removal of the 
spleen iron may be lost from the body. Our investiga- 
tions 22 show, however, that this disturbance of iron utiliza- 
tion is transient, and that after a few weeks the elimina- 
tion of iron in the splenectomized animal differs in no way 
from the process in the normal animal. This suggests 
naturally that the storage of iron in the absence of the 
spleen is taken over by other tissues. As microchemical 
tests for iron showed no definite increase of iron in the 
lymph-nodes and liver, it seemed probable that the bone- 
marrow might be the chief depot of iron storage. Such 
a view was supported by the fact that all hyperplastic 
bone-marrows contain large amounts of altered blood- 
pigment, sometimes free, but occurring, for the most part, 
in large phagocytic cells. The activity of these phagocytic 
cells in transforming the iron of old blood-pigment in order 
that it may be utilized for red cells might, it was plausible 
to suppose, stimulate the other functions of the bone- 
marrow (that is, the erythrogenetic and leucogenetic func- 
tions) and cause eventually a replacement of the fatty 
marrow by a very cellular red marrow. 

In order to prove this hypothesis it was necessary to 
obtain some idea of the iron content of these marrows. 
Direct chemical analysis was out of the question on account 
of the small amount of material available and the varia- 



CHANGES IN BONE-MARROW lei 

tions in blood and bone content of different marrows. We 
therefore made a comparative study based on the use of 
the microchemical reaction for iron. This demonstrated 
at once that all red marrows in our series have a large con- 
tent of iron, and that fatty marrows contain very little 
or no iron. On the other hand, when the marrows of non- 
splenectomized dogs rendered hyperplastic by anaemia or 
infection were examined it was found that these also had 
a large iron content. Thus in a group of seventeen non- 
splenectomized dogs iron was present in the marrow in 
large amounts in four, in moderate amounts in two, in 
small amounts in four, and in seven none was found. On 
the other hand, in twenty-seven splenectomized dogs, iron 
was present in large amounts in ten, in moderate amounts 
in three, small amounts in four, and absent in ten. 

In both groups the amount of iron w T as in direct pro- 
portion to the degree of hyperplasia. These observations 
point, therefore, to the conclusion that a red marrow is 
always rich in iron, but it is impossible to say whether the 
cellular hyperplasia or the iron deposition is primary. 
Under the circumstances, it is also impossible to conclude 
that the late hyperplasia of marrow following splenectomy 
is an attempt to conserve iron. Moreover, the irregularity 
of our results, as shown by the failure of hyperplasia in 
four animals, representing respectively the eighth, ninth, 
tenth, and twenty-second months after splenectomy, pre- 
vents, in the present state of our knowledge, an adequate 
explanation of the cause of the transformation from yellow 
to red marrow. However, the tardiness with w^hich hyper- 
plasia of the bone-marrow appears after splenectomy, de- 
spite the presence of an anaemia of considerable grade, may 
well bear some causative relation to the slow degree of 
11 



162 THE SPLEEN AND ANAEMIA 

blood regeneration that follows the administration of 
hemolytic agents to such animals. 

The divergent results in this study are characteristic 
of all phases of experimental work on the spleen, and 
doubtless are to be explained by the fact that removing 
the spleen takes away only one organ of a system com- 
posed of liver, spleen, lymph-nodes, and bone-marrow, and 
that the interrelations which exist in this system may, or 
may not, under varying circumstances, bring into play 
compensations of the greatest importance in determining 
the degree of blood destruction or regeneration and there- 
fore the degree of change in the bone-marrow. 

A search of the literature of splenectomy in man, 
although it reveals evidence of the occurrence of red mar- 
row in various forms of splenic ansemia, offers little of im- 
portance concerning the changes which occur in the bone- 
marrow after removal of the normal spleen. Several refer- 
ences are made to the occurrence of pain in the long bones 
after splenectomy, and by some this has been assumed to 
be evidence of hyperplasia within the rigid bony canal. 
The only note of the direct examination of the bone-marrow 
after splenectomy is that of Riegner, 375 who found active 
proliferation of the marrow of the femur in a man whose 
leg was amputated for gangrene four weeks after splenec- 
tomy for trauma. It is therefore impossible, on account 
of this paucity of data concerning the changes in man, to 
bring them into relation with our experimental results. 

Conclusions. — Splenectomy in the dog causes, as a 
rule, a transformation of the fatty marrow of the long 
bones into a richly cellular red marrow. 

During the early periods, one to three months, the 
change in the marrow is slight and either focal or pe- 






CHANGES IN BONE-MARROW 1(33 

ripheral; after six to twenty months the replacement of 
fat by marrow cells is complete or nearly so. Excep- 
tions were, however, seen in four animals representing 
the eighth, ninth, tenth, and twenty-second months 
respectively. 

The evidence at hand does not support the theory that 
this hyperplasia is compensatory either to the anaemia 
caused by splenectomy or to an increased haemolysis in the 
lymph-nodes. It is possible that it may be a concomitant 
of the activity of the bone-marrow in taking over, in the 
absence of the spleen, the function of storing and elaborat- 
ing the iron of old blood-pigment for future utilization by 
new red cells, but our studies do not fully support this 
view. 



CHAPTER VII 

THE CHANGES IN THE LIVER AND LYMPH-NODES AFTER 

SPLENECTOMY 

DISCUSSION 4 OF THE LITERATURE. CHANGES IN 
LYMPH-NODES. PHAGOCYTOSIS OF RED CELLS 
BY ENDOTHELIAL CELLS OF LYMPH-NODES 
AND LIVER. MICROCHEMICAL TEST FOR IRON 
IN LYMPH-NODES AND LIVER. 

Much of the early literature concerning compensatory 
changes in the lymph-nodes is bound up with the question 
of the regeneration of the spleen after partial or complete 
extirpation and more recently with problems concerning 
the hsemolymph-nodes. As this literature has been col- 
lected very completely by Warthin, 461 we will give only a 
general summary of it in the light of his investigation. The 
earliest detailed investigations are those of Tizzoni and 
Fileti, 439 who observed in the splenectomized dog an in- 
crease in size of the retroperitoneal and thoracic lymph- 
nodes, which were distinctly red in color. In two dogs, 
splenectomized for fifty-four days and three and a half 
months respectively, they found a new formation of spleen- 
like nodules in the omentum. These they believed to be 
formed directly from adipose tissue by an absorption of 
fat and a transformation of the fat cells into reticulum. 
Leucocytic infiltration followed, as also proliferation of 
endothelium, which produced eventually a pulp-like tissue, 
in the meshes of which were red blood-cells. Around the 
whole a connective-tissue capsule was formed. Later, in 
164 



CHANGES IN LIVER AND LYMPH-NODES 165 

1882, Tizzoni 438 found somewhat similar bodies in the 
gastrosplenic ligament, in connection with indurative sple- 
nitis in the dog, and after splenectomy numerous newly- 
formed nodules throughout the subperitoneal fat, over the 
diaphragm, and in the pelvic, sterno-abdominal and sub- 
cutaneous fat tissue. Foa, 119 in 1883, denied the new 
formation of such nodes, and explained them as preexist- 
ing nodes, changed in color by hemorrhage or other patho- 
logical conditions. In the meantime, however, Wino- 
gradow 475 had described in dogs killed 132, 517, and 760 
days after splenectomy changes in existing lymph-nodes 
similar to those observed by Tizzoni. On account of the 
presence of red cells and pigmented cells in the sinuses of 
these nodes, he believed these structures to have a share 
in blood destruction, and that possibly the anaemia occur- 
ring after splenectomy could in this way be explained. 

Zezas 485 found that after splenectomy the mesenteric 
and bronchial lymph-node of the rabbit became swollen, 
dark red in color, and firmer in consistency, and quotes 
Hegar and Simon as finding similar changes in the mesen- 
teric lymph-nodes of the cat. Tizzoni 438 and Ceresole 69 
could not confirm these changes in the rabbit. Mosler 303 
found in a dog, splenectomized ten months, numerous 
spleen-like nodules of the size of a pea, scattered through- 
out the greater and lesser omentum. Microscopically, 
these were similar in structure to those found by Tizzoni 
and Winogradow, but Mosler regarded them as neo- 
plasms — hemorrhagic telangiectatic lymphoma — and not 
as newly-formed spleen or lymph-nodes. The lymph-nodes 
generally were not hyperplastic, and the bodies described 
above were not constantly present; in one dog, for ex- 
ample, killed after eleven months, no changes in the lym- 



166 THE SPLEEN AND ANiEMIA 

phoid tissue were found. Mosler concludes, nevertheless, 
that after splenectomy compensatory changes may occur 
in lymph-glands and bone-marrow. 

Gibson 14 ° found in splenectomized dogs enlarged 
mesenteric lymph-nodes containing both normoblasts and 
normocytes in their sinuses. Of other investigators, Eter- 
nod 107 , found in a fox, 161 days after splenectomy, a 
splenic nodule in the omentum and newly-formed lymph- 
nodes in the mesentery, the other lymph-nodes being en- 
larged and of a brownish color; Vulpius 460 found no 
enlargement of lymph-nodes in dogs dying after a few 
days, or killed five months after splenectomy; Lauden- 
bach 24 ° found that hyperplasia of the lymph-nodes was 
not constant, and that evidence of increased blood forma- 
tion was present in the bone-marrow only. 

An examination of Warthin's summary of the litera- 
ture concerning the lymph-nodes of man after splenectomy 
shows that no constant changes have been observed. Tem- 
porary local enlargement of lymphoid tissue has been ob- 
served and occasionally general enlargement; on the 
other hand, in many cases no changes whatever have been 
seen. 

In the congenital absence of the spleen, as in the case re- 
ported by Hodenpyl, 181 general enlargement of all the 
lymph-nodes of the body is found, as also usually a new 
formation of lymphoid tissue in the adrenals and liver. 

Warthin's studies 461 were upon sheep and goats which 
normally have numerous ha3molymph-nodes in the pre- 
vertebral fat. One and two weeks after splenectomy, 
lymph- and haemolymph-glands presented evidence of an 
increased number of pigment-bearing phagocytes and 
eosinophiles and a proliferation of lymphoid tissue gen- 



CHANGES IN LIVER AND LYMPH-NODES 167 

erally. At the end of two months these changes were more 
marked and, in addition, new formation of haemolymph- 
nodes in adipose tissue was evident. The changes were 
progressive, and at the end of five months are described 
as follows: " Great hyperplasia and new formation of 
lymph-nodes, new formation of haemolymph-nodes in adi- 
pose tissue, marked haemolysis, eosinophiles in the lym- 
phoid tissues, pigmentation of the liver, and slight lym- 
phoid changes in the fatty marrow." Leucocytosis was 
most marked at the end of two months. 

From this summary it is evident that two types of 
changes have been found : ( 1 ) A peculiar new formation 
of lymph-nodes (Tizzoni, Winogradow and Hosier) , prob- 
ably identical with the haemolymph-node described by 
Warthin, and (2) an inconstant hyperplasia of preexisting 
lymph-nodes with reddish or reddish-brown discoloration. 

As to the formation or destruction of red cells by the 
lymph-nodes after splenectomy, divergent opinions are 
held. Gibson 140 and Laudenbach, 240 among others, sup- 
port the theory of red-cell formation ; Warthin saw no evi- 
dence of this. On the other hand, the latter states that his 
findings indicate that the splenic functions of haemolysis 
and leucocyte formation are, in the absence of the spleen, 
taken over by the lymph- and haemolymph-nodes. So far 
as the function of haemolysis is concerned, this view is 
supported by Morandi and Sisto, 298 who found in the 
haemolymph-nodes of dogs evidence of increased haemolysis 
after splenectomy. According to Warthin, " the haemo- 
lytic function of the haemolymph-nodes and hyperplastic 
lymph-glands exceeds that of the primitive spleen, causing 
an excessive destruction of red cells. The resulting anaemia 
is later compensated for by an increased activity on the 



V 



168 THE SPLEEN AND ANAEMIA 

part of the bone-marrow. It would appear, therefore, that 
the removal of the spleen leads to an increased production 
or retention of some hsemolytic agent usually disposed 
of by the spleen. The effect of this hemolytic agent 
is either to stimulate the phagocytes in the hsemolymph- 
nodes to increased activity, or to change the red cells so 
that they are more easily destroyed by these phagocytes." 

This view is not shared by Banti, 29 who, although he 
considers the lymph-nodes, liver, and bone-marrow to be 
secondary organs of haemolysis, denies that they may com- 
pensate for the hsemolytic activity of the spleen. Indeed, 
it is upon this argument that he bases the beneficial results 
of extirpation of the spleen in hsemolytic splenomegaly. 

Changes in the Lymph-nodes. — All animals used in 
our studies of the effect of splenectomy have been carefully 
examined 333 at autopsy in the hope of finding the hsemo- 
lymph-nodes occasionally noted by other investigators. In 
this we have not been successful. Never upon gross ex- 
amination have we found structures corresponding to 
Warthin's description, and the occasional doubtful hsemo- 
lymph-node has always proved upon histological examina- 
tion to be a hsemorrhagic or otherwise pathologically altered 
lymph-node. Upon this point we have felt relieved since 
Dr. Warthin assured us that the dog is a very unsatisfactory 
animal for the study of the hsemolymph-node. Still, it has 
been a matter of surprise to us that we have found in none 
of the many dogs we have examined the bodies described 
by Tizzoni, Winogradow, and Mosser. 

The second change in the lymph-nodes — a reddish or 
reddish-brown discoloration — described by other observers 
we have frequently seen. More frequently this has been a 
reddening limited to the centre of the node, at other times a 



CHANGES IN LIVER AND LYMPH-NODES 169 

diffuse reddening. In animals spleneetomized ten months 
or more the red usually gives way to a brownish color, 
especially in the inguinal and axillary lymph-node. 

Hyperplasia of the lymph-nodes has been common in 
animals killed shortly after splenectomy, but in those rep- 
resenting the longer periods it has been impossible to dis- 
tinguish any appreciable increase in size and certainly no 
new formation. 

On the other hand, the lymph-nodes (as also the liver) 
in a small group of animals presented changes which 
appear to be of significance in connection with the general 
problem of blood destruction in the absence of the spleen. 
These changes are (1) a proliferation of the endothelial 
cells, and (2) an increase in the phagocytic power of these 
cells for red blood-corpuscles. 

It is not necessary to discuss the voluminous literature 
concerning the destruction of red cells. This has been 
well presented up to 1895 by Gabbi 135 and up to 1901 
by Hunter. 188 The more recent literature has added little 
either in fact or theory that is new. Out of the mass of 
contradictory statements there is uniformity of opinion 
on only two points: (1) That large endothelial cells of 
the spleen (the red blood-corpuscle-carrying cells) have 
the power to engulf red blood-cells; and (2) that the 
presence (in anaemia and malaria) of blood-pigment in 
the cells (Kupffer's cells) of the liver capillaries indicates 
that these cells play some important part in the destruction 
of red blood-cells. On the other hand, it is not generally 
admitted that the endothelial cells of the lymph-nodes 
likewise have this power. That phagocytosis of red cells, 
wherever it occurs, leads ultimately to the 1 freeing of 
haemoglobin, which eventually reaches the liver and is 



170 THE SPLEEN AND ANAEMIA 

transformed into bile-pigment, is the opinion of all who 
support the theory that this mechanism plays a part in the 
destruction of red blood-cells. There is, however, no 
uniformity of opinion as to whether the haemoglobin is set 
free in the liver from red cells carried there by the phago- 
cytes or whether it is set free by the phagocytes elsewhere 
and carried to the liver in another way. 

It is only with one phase of the subject, the role of 
endothelial cells in engulfing red cells in the absence of the 
spleen, that we will concern ourselves here. Our hypoth- 
esis is that in the absence of the spleen the endothelial 
cells of the lymph-nodes and liver compensate, at times 
of excessive blood destruction, for the loss of similar cells 
of the spleen. 

This possibility was first brought to our attention in 
the routine examination of tissues from splenectomized 
dogs which had received specific hsemolytic immune serum. 
So striking were some of the pictures that we undertook, 
for the sake of control, the study of the liver and lymph- 
nodes from a number of normal dogs, of normal dogs re- 
ceiving hsemolytic serum, and of dogs which had been 
splenectomized for various lengths of time, but which had 
not received hsemolytic serum. 

The literature of splenectomy offers little aid in 
determining the histological changes occurring in the 
lymph-nodes after removal of the spleen. In the litera- 
ture at our disposal no definite descriptions have been 
found except those of Warthin, who found in sheep and 
goats an increase in the phagocytic power of the endo- 
thelial cells for red blood-corpuscles. Gabbi, who worked 
with the guinea-pig, states that a transient increase of the 
red blood-corpuscle-carrying cells may possibly occur in 



CHANGES LN LIVER AND LYMPH-NODES 171 

early periods after splenectomy, but that after three to six 
months they are no more abundant than in the normal 
animal. 

The lymph-nodes studied have been for the most part 
the mesenteric, gastrohepatic, prevertebral, and bronchial. 
In the normal animal these have been examined more 
particularly for the frequence of mitosis, for the number 
of endothelial cells in the sinuses, and for the presence 
of cells containing red blood-corpuscles. Careful study 
of nodes from five normal animals showed that mitotic 
figures are found only after prolonged search and are 
usually limited to the follicles. The number of endothelial 
cells varies, but usually is not great, and they never occur 
in large masses in the sinuses. These cells, however, not 
infrequently contain old blood-pigment, and occasionally 
a cell may be seen containing one or two red blood- 
corpuscles. 

The lymph-nodes of five animals splenectomized for 
three, four (two), thirty-nine and eighty-four days and 
not subjected to the action of hemolytic serum have been 
studied in the same way. In two animals representing 
respectively four and eighty-four days the lymph-nodes 
differed in no way from the normal; in the other animals 
mitotic figures were abundant in the follicles, and the 
endothelial cells in the sinuses were greatly increased in 
number. Prolonged search, however, failed to demonstrate 
mitotic figures in the latter cells, and, although they occa- 
sionally contained one or two red blood-corpuscles, this 
power of phagocytosis did not appear to be greater than 
in the non-splenectomized animal. The increase in the 
number of endothelial cells was, however, very striking. 

The lymph-nodes of five normal dogs, which had received 



172 



THE SPLEEN AND ANAEMIA 



specific hemolytic immune serum and had died or been 
chloroformed, after periods varying from twenty-four 
hours to nine days, showed the lesions usually described 
as common to various cytotoxic sera 232 and especially to 
lymphotoxic sera. 114 These are oedema, increase of poly- 
morphonuclear leucocytes, focal areas of necrosis, abundant 

TABLE XLVII 

Changes in the Lymph-nodes After Splenectomy and the Injection of 

Hemolytic Serum 



Experi- 
ment No. 


Period 

after sple- 
nectomy 


Period 

after 
serum 


I 


3 days 


36 hours 


II 


300 days 


36 hours 


III 


285 days 


18 hours 


IV 


225 days 


48 hours 


V 
VI 


15 days 
27 days 


3 days 
3 days 


VII 


33 days 


4 days 


VIII 


65 days 


8 days 


IX 
X 


6 days 
3 days 


9 days 
9 days 


XI 


103 days 


10 days 


XII 


25 days 


15 days 



Effect of serum 



Hemoglobinuria 

Severe jaundice 

No record 

Hemoglobinuria 

Hsemoglobinuria 
Hemoglobinuria 

Jaundice 

Hemoglobinuria 

Hemoglobinuria 

No hemoglobinuria or 

jaundice 
No hemoglobinuria 
(spontaneous jaundice) 
Jaundice 



Histology- 



Extreme phagocytosis of 
red cells 

Well marked phagocyto- 
sis of red cells 

Well marked phagocyto- 
sis of red cells 

Moderate phagocytosis ' 
of red cells 

Negative 

Proliferation of endothe- 
lial cells 

Proliferation of endothe- 
lial cells 

Proliferation of endothe- 
lial cells 

Negative 

Negative 

Proliferation of endothe- 
lial cells 

Proliferation of endothe- 
lial cells 



mitotic figures in the follicles, and slightly greater fre- 
quency of large endothelial cells capable of phagocytosis 
of red cells. 

Of animals that had been splenectomized and had re- 
ceived hemolytic serum as well, twelve were available for 
histological examination. Of these, three showed no change 
in the lymph-nodes and five showed a well-marked in- 



CHANGES IN LIVER AND LYMPH-NODES 173 

crease in the number of endothelial cells in the sinuses, 
but no increase in power of phagocytosis. In the four 
remaining animals the sinuses contained a great number 
of large endothelial cells filled with red blood-corpuscles. 
The analysis of these findings is somewhat difficult, as 
three factors must be considered: (1) The length of time 
after splenectomy ; ( 2 ) the lapse of time between adminis- 
tration of hemolytic serum and the death of the animal; 
and (3) the degree of red-cell destruction caused by the 
serum. 

These factors are brought out in Table XL VI I. 

From this analysis it is seen that the proliferation of 
the endothelial cells did not occur in the animals (V, IX, 
and X) splenectomized for periods of from three to fifteen 
days, but was evident in five (VI, VII, VIII, XI, and 
XII) in which the time elapsing since splenectomy was 
27 to 103 days. On the other hand, the lymph-nodes of 
these animals did not present evidence of increased phago- 
cytosis of red cells. Whether this was due to the period 
which had elapsed (three to fifteen days) since injection 
of serum could not be determined, but this was probably 
the case. 

Certainly it was not due to failure of haemolysis, for 
at least two of these animals (VI and VIII) presented 
evidence of extreme blood destruction. That the period 
of time elapsing may be an important factor is shown by 
the fact that all animals (four) in which there was evidence 
of extensive phagocytosis of red cells represent periods 
of eighteen to forty-eight hours after injection of the 
serum. In the absence of exact knowledge of the length 
of time necessary for the destruction of red cells by phago- 
cytic endothelial cells, it is useless to surmise, but one can- 



174 THE SPLEEN AND ANAEMIA 

not escape the fact that in this investigation all evidence 
of active phagocytosis is seen in animals dying within forty- 
eight hours. It is possible, therefore, that the destruction 
of red cells by phagocytosis may be completed within forty- 
eight hours, and this view is supported by the frequency 
with which pigment is found in the lymph-nodes at later 
periods. 

It is also evident that the time elapsing since splenec- 
tomy bears no relation to the occurrence of phagocytosis 
of red cells, for the most marked example of the latter was 
seen in a dog dying three days after splenectomy, while 
moderate and well-marked phagocytosis occurred likewise 
after seven and one-half, nine and one-half and ten months. 

Recently Karsner, Amiral, and Bock 208 have confirmed 
these results and have added some interesting observations 
concerning the time element. Their conclusions are as 
follows : 

In cats the same phenomenon of phagocytosis of red 
blood-corpuscles in the liver and lymph-nodes takes place 
as in the dog. In the series of splenectomized animals 
killed three, six, twelve, twenty- four, and forty-eight hours 
after injection we found at three hours hyaline thrombosis, 
large numbers of mitotic figures, and in three lymph-nodes 
two phagocytes containing each one red blood-corpuscle 
and showing a certain amount of pigment phagocytosis; 
at six hours there was karyorrhexis in the central parts of 
the follicles, marked mitosis, phagocytosis of red blood- 
cells and of pigment, more marked in the central sinuses 
than in the peripheral sinuses. Digestive vacuoles in these 
phagocytes contained only a few erythrocytes. At twelve 
hours there was marked phagocytosis of the red blood-cor- 
puscles in the central and peripheral sinuses, also phago- 



CHANGES IN LIVER AND LYMPH-NODES 175 

cytosis of pigment granules. At twenty- four hours the 
necrosis in the follicles did not appear to be severe; the 
phagocytosis of the red blood-corpuscles was seen princi- 
pally in the peripheral sinuses. At forty-eight hours there 
was still hyaline thrombosis, very little evidence of necrosis, 
marked phagocytosis of pigment both in the central and 
peripheral sinuses. Practically no red blood-corpuscles 
were within the phagocytes, although simple acidophilic 
granules, apparently erythrocytic fragments, were found. 

The story of the phagocytosis appears to be that it 
begins at about three hours after injection of the immune 
serum, continues progressively, and reaches its height at 
somewhere between twelve and twenty-four hours after 
injection, and then the destruction of the corpuscles goes 
on, so that at forty-eight hours there is nothing left but 
pigment and corpuscular fragments. Furthermore, with 
the passage of time the individual phagocytes become 
more and more filled with erythrocytes until about twelve 
to twenty-four hours, at which time there is a disappear- 
ance of the erythrocytes with the substitution of the pig- 
ment granules. The origin of the phagocytes appears to 
be particularly the endothelial cells of the sinuses, but in 
many of the lymph-nodes it was found that the individual 
cells of some of the smaller blood-vessels were swollen and 
also phagocytic, and it is possible that this is an important 
matter in connection with the origin of the phagocytic cells 
and also an important way of explaining the presence of 
red blood-corpuscles within the lymphatic sinuses. Careful 
examination failed to show anything in the nature of rup- 
ture of any of the blood-vessels. 

Another phase of Karsner's work had to do with the 
question of hgemopsonins ; that is, w T ith the possibility of 



176 THE SPLEEN AND ANEMIA 

the spleen having some relation to a substance which ren- 
ders the red cells more susceptible, or otherwise, to phago- 
cytosis, and the possible increase or decrease of such a 
substance after splenectomy. He summarizes 208 the re- 
sults of this phase of the investigation, as follows: 

1. Splenectomy produces no change in hasmopsonins 
of the circulating blood that is clearly demonstrable by 
in vitro tests. 

2. The venous blood returning from the kidney and 
from the spleen and the venous blood of the portal vein, 
of the right auricle, and of the left ventricle showed the 
same content of hsemopsonin. 

3. Extracts of washed spleen, kidney, pancreas, and 
liver showed no influence over the phagocytic activity of 
the corpuscle, serum, and exudate mixture used in the 
opsonic work. 

4. Extracts of the lymph-nodes of splenectomized dogs 
and the extract of the lymph-nodes of normal dogs have 
no influence over the phagocytic mixture mentioned under 
heading 3. 

Changes in the Liver. — Examination of the stellate 
endothelial cells ( Kupffer's cells ) of the liver 333 has been 
rendered difficult on account of the intense congestion and 
abundant necrosis which occur in the liver after the admin- 
istration of hemolytic immune serum. For this reason we 
have not always been able to correlate the evidence of pha- 
gocytosis in the liver with the lesion described in the lymph- 
nodes during the early (forty-eight hour) period. Definite 
evidence, however, of phagocytosis has been found in four 
animals, representing periods of one, two, eight, and nine 
days after the administration of serum, and representing, 
respectively, periods of three, 225 sixty-five, and six days 



CHANGES IN LIVER AND LYMPH-NODES 177 

after splenectomy. Also in a fifth animal, twenty-five days 
after splenectomy and fifteen days after the administration 
of the serum, the cells of the capillaries contained small 
balls of yellow pigment, apparently representing altered 
haemoglobin. 

As controls we have examined the livers of several nor- 
mal dogs and of nine splenectomized dogs not receiving 
serum, but without finding evidence of phagocytosis on 
the part of the cells of the liver capillaries, or of prolifera- 
tion of these cells. The splenectomies in this series repre- 
sented periods of from three to eighty-four days ; five under 
ten days and three over twenty days. 

Likewise we have examined the livers of nine normal 
dogs receiving hemolytic serum. In two of these the endo- 
thelial cells appeared to be increased somewhat in number, 
but no undoubted evidence of phagocytosis could be ob- 
tained. All other livers examined showed no changes in 
the cells of the capillaries. 

MlCROCHEMICAL TESTS FOR IRON IN LYMPH-NODES 

and Liver 
Warthin, in his study of the lymph-nodes and haemo- 
lymph-nodes of sheep and goats, found in these organs, 
several months after splenectomy, evidence of increased 
blood destruction. This we have observed in the dog, in 
so far as it is shown by phagocytosis of red cells, only after 
the administration of a hsemolytic poison; in the ordinary 
course of events, no increased phagocytic activity on the 
part of the endothelial cells of the lymph-nodes of the 
splenectomized animal is seen. This observation we have 
confirmed by examining a number of lymph-nodes and 
liver by the usual microchemical method of demonstrating 
the presence of iron. The lymph-nodes of fourteen sple- 

12 



178 THE SPLEEN AND ANEMIA 

nectomized dogs showed a considerable amount of iron in 
three, slight amounts in five, and none in six. The animals 
examined represented periods of eleven days to twenty- 
two months after splenectomy. In the lymph-nodes of 
fifteen normal animals similarly examined moderate 
amounts of iron were found in eight, slight amounts three 
times, and in four none. It is evident, therefore, that in 
the dog the iron content of the lymph-nodes after splenec- 
tomy differs little from normal. The liver likewise shows 
no increased deposition of iron. Of fourteen livers from 
splenectomized dogs, four showed slight deposition of iron 
in Kupffer's cells, while ten showed none. At the same 
time the livers of six normal dogs were similarly exam- 
ined; in three slight deposits of iron were found, and in 
three none. 

Protocols illustrating the histological changes in the 
lymph-nodes and liver follow: 

Dog 32. — Splenectomy was performed under ether 
anaesthesia on July 19, 1911; on March 8, 1912, specific 
hemolytic immune serum was injected intravenously. The 
red cells dropped within three hours from 6,120,000 to 
5,200,000 per cubic millimetre, and the haemoglobin, after 
twenty hours, to 42 per cent. Hemoglobinuria was pres- 
ent, and death occurred after forty-eight hours. 

Histology. — The liver-cells are pale, granular, stain 
poorly, and present here and there small areas of focal 
necrosis. The capillaries are dilated and contain much 
granular material and, as seen by the low power, numerous 
isolated round and oval clumps of red blood-corpuscles. 
By higher power of the microscope these clumps of red 
cells are found to be, in large part, within endothelial cells 
(Plate I, Fig. 4) . Some of the red cells stain well with 
eosin. others appear as shadows. Other endothelial cells 



CHANGES IN LIVER AND LYMPH-NODES 179 

are seen which contain mere fragments of red cells or 
masses of granular, yellow pigment, or large, yellow hya- 
line balls of apparently fused red cells. Attempts to dem- 
onstrate similar phagocytic cells in the large vessels of the 
liver and of other organs failed; they were present, how- 
ever, in the sinuses of the lymph-nodes. 

Dog 34. — Splenectomy was performed under ether 
anaesthesia on March 11, and haemolytic serum adminis- 
tered intravenously on March 14. Death occurred on 
March 15, after reduction of red cells to 1,960,000 and 
haemoglobin to 57 per cent. Haemoglobinuria was marked. 

Histology. — A mesenteric lymph-node shows hemor- 
rhage, oedema, and extensive infiltration with polymor- 
phonuclear leucocytes. The sinuses, both peripheral and 
central, are closely packed with large, pale, endothelial 
cells, nearly all of which contain red blood-cells, a single 
high-power field showing thirty to forty phagocytic cells 
(Plate I, Figs. 1 and 2). The number of engulfed red 
blood-cells varies, but is usually large, ten to twenty not 
infrequently being found in a single cell. In many en- 
dothelial cells, on the other hand, the red blood-cells have 
fused to form large, round, or oval hyaline masses still 
staining deeply with eosin. Between the phagocytic cells 
is much granular, eosin-staining material suggesting dis- 
integrated red cells, mingled with serum, through which 
run irregular threads of fibrin. Here and there in the 
follicles are small areas of necrosis. Moderate leucocytic 
infiltration is seen throughout the section. Phagocytic 
cells cannot be demonstrated in the blood-vessels or in a 
tangle of lymphatic vessels present at one side of the node. 

Other lymph-nodes (gastrohepatic, prevertebral, and 
bronchial) present the same lesions. 



180 THE SPLEEN AND ANAEMIA 

The liver of this animal showed widespread necrosis, 
but in the non-necrotic areas phagocytic endothelial cells 
are found in the capillaries (Plate I, Fig. 3). 

Summary 

In a large proportion of dogs that have been splenec- 
tomized for periods of two weeks or more one finds a great 
increase in the number of endothelial cells of the lymph- 
nodes. In most splenectomized dogs that succumb to an 
injection of hemolytic immune serum within forty-eight 
hours the sinuses of the lymph-nodes contain large num- 
bers of endothelial cells, phagocytic for red blood-cells. 
This is not seen in normal dogs receiving hemolytic serum. 
Likewise a similar power of phagocytosis is seen fre- 
quently in the stellate cells (Kupffer's) of the capillaries 
of the liver. Both in the lymph-nodes and the liver these 
cells appear to be formed in situ; we find no evidence that 
they have been transported to these organs. 

Such findings suggest the development of a compen- 
satory function on the part of the lymph-nodes and pos- 
sibly the liver. Normally the spleen contains cells which 
have the power to engulf and presumably to destroy the 
red blood-corpuscles. In certain pathological conditions 
this function is frequently greatly augmented and may 
sometimes be shared by the lymph-nodes ; for example, in 
typhoid fever, as was first clearly shown by Mallory. 270 
Our observations suggest that in the absence of the spleen 
this function of forming red blood-corpuscle phagocytic 
cells, normally a minor activity of the lymph-nodes, be- 
comes highly developed in the latter organs, and that in 
times of stress these cells and the stellate cells of the liver 
thus assume, in part at least, the function of destroying 
red blood-corpuscles by phagocytosis. 



CHAPTER VIII 

METABOLISM STUDIES ON THE DOG BEFORE AND 
AFTER SPLENECTOMY 

Although early in our work we studied the influence 
of splenectomy upon iron metabolism (see p. 112), it did 
not at that time seem advisable, on account of the generally 
negative results of others, to study the effect of splenec- 
tomy upon nitrogen metabolism. Later, however, when 
interested in the influence of diet in connection with the 
ansemia of splenectomy, we became aware of the observa- 
tions of Richet, 374 which seemed to indicate that in order 
to maintain the weight of a splenectomized dog a much 
larger amount of food is required than is the case with the 
normal dog. 

These studies suggested to us a possible explanation of 
the contradictory and confusing results obtained in our 
dietary studies, and, as nitrogen metabolism had never been 
studied in animals in nitrogen equilibrium, we undertook 
a detailed investigation in the hope of arriving at some 
definite conclusion concerning (1) the influence upon 
metabolism of the absence of the spleen, as contrasted 
with (2) the influence on metabolism of the anaemia which 
usually follows splenectomy. 

Previous Investigations 

Paton's 329 investigation included studies of the nitro- 
gen metabolism and the elimination of salts in a single 

181 



182 THE SPLEEN AND ANAEMIA 

dog before and after splenectomy. Observations were 
made during fasting and on (1) meat, (2) oatmeal and 
milk, and (3) rich nuclein diets. The first post-splenec- 
tomy metabolism study was made twenty-six days and the 
last four months after the operation. Paton's general 
conclusion is that under the various conditions of his experi- 
ments splenectomy causes no essential difference in the 
course or nature of the metabolism. 

In Richet's first investigation 374 nine splenectomized 
dogs were contrasted with six normal dogs. No metabolism 
studies and no examinations of the blood were made. Con- 
clusions were based on records of food taken and the weight 
of the animals at various intervals. The increased con- 
sumption of food by the splenectomized animals is thought 
by Richet to be due to an increased catabolism in those 
animals and not to any disturbance of digestion. In a later 
report 374 he refers to studies of seventeen splenectomized 
dogs, of which five were under observation for about two 
years, and confirms the conclusions of his earlier report. 
In this connection it is a matter of importance that the 
conclusions are based on the averages of two groups of dogs 
of widely different weights, Richet has not contrasted 
splenectomized dogs of given weight with normal dogs of 
the same weight, but if one selects from his tables dogs 
of the same weight the differences in food consumption are 
found to be very slight. Only two dogs were studied both 
before and after splenectomy. 

Mendel and Jackson, 285 who investigated the relation 
of the spleen to purin metabolism, found that in splenec- 
tomized dogs and cats no changes occurred. 

Verzar 452 has found that extirpation of the spleen in 
dogs has no appreciable effect upon the respiratory gas 



METABOLISM STUDIES ON THE DOG 183 

exchange. A similar conclusion was reached by Koren- 
chevski 224 as regards both gaseous and nitrogenous metab- 
olism. No other experimental studies of the influence of 
splenectomy are available, except the brief note of Austin 
and Ringer 21 to the effect that in the dog the absence of 
the spleen does not in any way modify the course of the 
glycosuria caused by pholorhizin. 

Methods 

The four dogs used in this study were placed upon a 
constant diet of beef (usually beef-heart) , lard, and sugar, 
the amounts of each of which constituents varied accord- 
ing to the caloric needs of each dog. The standard diet con- 
tained 0.4 gm. of nitrogen per kilo, and 70 calories per kilo, 
of body weight. A small amount of sodium chloride was 
given each day, and a sufficient amount of bone-ash was 
added to ensure well-formed fseces. The water intake for 
each day was constant. To some animals the beef-heart 
was given raw; in other instances it was boiled. After 
one or two weeks on the special diet, if the weight of the 
animal remained constant, a preliminary metabolism study, 
covering a period of seven days, was made. If the results 
of this were satisfactory, the animal was then splenecto- 
mized and the metabolism studies resumed at various inter- 
vals after the operation. In each experiment the diet after 
operation was always the same as before, and was con- 
tinued without change in the intervals between periods of 
metabolism study. Analyses were made of all foods for 
fat and total nitrogen. During the periods of study the 
animals were kept in the usual metabolism cages. They 
were catheterized at the end of every twenty-four hours 
and the faeces marked by carmine. 



184 THE SPLEEN AND ANAEMIA 

In the analysis of the urine the total nitrogen was 
determined by the Kjeldahl-Gunning method, ammonia 
by Folin's method, 120 creatine and creatinine by Folin's 
method, 121 and the hydrogen ion concentration according 
to Henderson's technique. 173 In the study of feces the 
Kjeldahl-Gunning method was used for total nitrogen, 
the Folin-Wentworth method for fat, 122 and Neumann's 
method 315 for iron. 

The removal of the spleen, an essentially bloodless 
operation, was done under ether anaesthesia. 

Results 

The details of our studies of nitrogen metabolism are 
shown in Tables XL VIII to LI, and of fat metabolism in 
Table LIL 

Nitrogen Metabolism. — Table XLVIII represents the 
earliest period of metabolic study (three days) after sple- 
nectomy. The animal showed no loss of weight, no ill- 
effect of the operation, and the conditions were therefore 
ideal for the detection of any slight early changes in metab- 
olism which might be due to the absence of the spleen. 
No variations in nitrogen partition were observed, how- 
ever, and the nitrogen equilibrium was maintained: an 
average daily balance before operation of 0.45 gm. and 
after operation of 0.46 gm. 

Table XL IX shows practically the same results, thir- 
teen days and eight weeks after splenectomy. The animal 
was in nitrogen equilibrium before splenectomy, and main- 
tained that condition after splenectomy. The general 
metabolism shows entirely normal results. The utilization 
of nitrogen was in no way interfered with : it was 94 per 



METABOLISM STUDIES ON THE DOG 



185 



cent, before operation and 95 and 93 per cent, in the post- 
splenectomy periods. 

In Table L, which presents observations two, six, and 
ten weeks after splenectomy, the results in the third and 
fourth periods (sixth and tenth weeks) are similar to those 

TABLE XLVIII 

Dog 57. Nitrogen Metabolism Before and Three Days After 
Splenectomy 















Urine 




-a 








* 










"3 


c 
a) 




Date 




o 


1* 


s§ 




z 


V 




a> 






(V 


■♦» 


- 1 >, 


tss 


03 


£ 


a 


"3 


• 




*C 


a 




60 


OS 





o a 


©.-a 

o5~ 


ah 

.2 a 


*o3 


o 

e 


03 


03 


00 

e 


_ © 


a. 




0) 

* 


£ 


a 

< 


P. ui 
02 


© fi 


0J 


O 

H 


s 
< 




I- 









J3 




kg. 




cc. 


10 






gm. 


gm. 


gm. 


gm. 


gm. 






Feb. 28 


10.6 


4.80 


295 


29 


Acid 


6.90 


3.45 


0.13 


0.289 


0.478 


0.73 


4.18 


+0.62 


Mar. 1 


10.8 


4.80 


175 


34 


Acid 


6.50 


3.76 


0.15 


0.270 


0.357 


0.73 


4.09 


+0.71 


Mar. 2 


10.8 


4.80 


225 


37 


Acid 


6.90 


3.44 


0.12 


0.289 


0.326 


0.73 


4.17 


+0.63 


Mar. 3 


10.8 


4.80 


225 


38 


Acid 


6.90 


3.57 


0.13 


0.285 


0.321 


0.73 


4.30 


+0.50 


Mar. 4 


10.8 


4.80 


190 


37 


Acid 


6.90 


3.65 


0.14 


0.289 


0.335 


0.73 


4.38 


+0.42 


Mar. 5 


10.9 


4.80 


200 


40 


Acid 


6.90 


3.86 


0.14 


0.289 


0.335 


0.73 


4.59 


+0.21 


Mar. 6 


10.9 


4.80 


220 


27 


Acid 


6.90 


4.02 


0.12 


0.279 


0.377 


0.73 


4.75 


+0.05 


Average . 


10.8 


4.80 


219 


35 




6.84 


3.62 


0.13 


0.284J0.361 


0.73 


4.35 


+0.45 


Mar. 7 


Splenectomy 


Mar. 10 


10.8 


4.80 


150 


45 


Acid 


6.15 


3.86 


0.18 


0.3110.310 


0.53 


4.39 


+0.41 


Mar. 11 


10.8 


4.80 


220 


35 


Acid 


6.50 


3.92 


0.15 


0.311 


0.310 


0.53 


4.45 


+0.35 


Mar. 12 


10.9 


4.80 


235 


37 


Acid 


6.50 


3.96 


0.14 


0.332 


0.285 


0.53 


4.49 


+0.31 


Mar. 13 


10.9 


4.80 


180 


40 


Acid 


6.50 


4.08 


0.13 


0.302 


0.320 


0.53 


4.61 


+0.19 


Mar. 14 


10.9 


4.80 


135 


45 


Acid 


6.15 


3.95 


0.15 


0.289 


0.267 


0.53 


4.48 


+0.32 


Mar. 15 


10.9 


4.80 


165 


37 


Acid 


6.15 


3.36 


0.13 


0.289 


0.259 


0.53 


3.89 


+0.91 


Mar. 16 


11.0 


4.80 


210 


42 


Acid 


6.90 


3.53 


0.08 


0.311 


0.283 


0.53 


4.06 


+0.74 


Average . 


10.9 


4.80 


185 


40 




6.41 


3.81 


0.16 


0.306 


0.291 


0.53 


4.34 


+0.46 



* Diet: raw beef, 150 gm.; lard, 50 gm.; sugar, 50 gm. 
t Expressed as negative logarithms. 

shown in Tables XLVIII and XLIX. In the early period 
after splenectomy, however, this animal showed a loss of 
appetite which caused, during the two weeks following 
operation, a loss in weight of 1.4 kilos. This loss of appe- 
tite was not due to infection or other post- operative dis- 



186 



THE SPLEEN AND ANEMIA 



turbances, but appeared to be due rather to a dislike of the 
lard in the diet. When the lard was cut out of the diet 
the animal ate readily, and later, when the lard was again 
added, no trouble was experienced. As may be seen in 
Table LII, this was the only animal which showed a high 



TABLE XLIX 



Dog 48. 


Nitrogen Metabolism Before and Two and 


Eight Weeks After 


Splenectomy 






* 

o 

J* 

C5 

•♦a 


Urine 


'3 
o 

93 


T3 

a 
as 

o 
a 
•c 

s ■ 




Date 


a 
% 


a 2 


S3 


at 


*3 


S3 

*3 
o 

a 


05 

a 

•a 

•3 

d 


m 

.9 


g 

a 




<D 




a 


ft M 


<DO 




o 


a 


8 


8 


S 


°® 


-a 




\? 


te 


< 


02 


f>s 


a u 


h 


< 


O 


o 


fa 


£"~ 


z 




kg. 




cc. 


10 






gm. 


gm. 


gm. 


gm. 


gm. 






Nov. 16 


13.4 


5.60 


175 


56 


Acid 


6.70 


5.35 


0.38 


0.300 


0.358 


0.34 


5.69 


-0.09 


Nov. 17 


13.4 


5.60 


250 


47 


Acid 


6.90 


5.48 


0.37 


0.338 


0.195 


0.34 


5.82 


-0.22 


Nov. 18 


13.4 


5.60 


225 


50 


Acid 


6.70 


4.91 


0.38 


0.352 


0.480 


0.34 


5.25 


+0.35 


Nov. 19 


13.4 


5.60 


210 


43 


Acid 


6.80 


5.33 


0.37 


0.368 


0.427 


0.34 


5.67 


-0.07 


Nov. 20 


13.4 


5.60 


200 


44 


Acid 


6.90 


4.80 


0.34 


0.361 


0.467 


0.34 


5.14 


+0.46 


Nov. 21 


13.4 


5.60 


235 


46 


Acid 


6.90 


4.91 


0.31 


0.368 


0.408 


0.34 


5.25 


+0.35 


Nov. 22 


13.3 


5.60 


265 


37 


Acid 


6.90 


4.77 


0.27 


0.385 


0.597 


0.34 


5.11 


+0.49 


Average . 


13.4 


5.60 


223 


46 




6.83 


5.08 


0.35 


0.3530.419 0.34 


5.42 


+0.18 


Nov. 24 


Splenectomy 


Dec. 7 


13.2 


5.60 


195 


55 


Acid 


7.14 


5.19 


0.31 


0.340 


0.575 


0.30 


5.49 


+0.11 


Dec. 8 


13.1 


5.60 


280 


35 


Acid 


6.00 


5.36 


0.34 


0.368 


0.513 


0.30 


5.66 


-0.06 


Dec. 9 


13.1 


5.60 


290 


33 


Acid 


6.90 


4.95 


0.29 


0.352 


0.636 


0.30 


5.25 


+0.35 


Dec. 10 


13.1 


5.60 


265 


39 


Acid 


6.80 


4.65 


0.29 


0.368 


0.513 


0.30 


4.96 


+0.64 


Dec. 11 


13.1 


5.60 


235 


38 


Acid 


6.80 


4.38 


0.29 


0.324 


0.527 


0.30 


4.68 


+0.92 


Dec. 12 


13.1 


5.60 


295 


36 


Acid 


6.80 


4.40 


0.27 


0.329 


0.558 


0.30 


4.70 


+0.90 


Dec. 13 


13.1 


5.60 


245 


35 


Acid 


6.80 


4.52 


0.23 


0.385 


0.672 


0.30 


4.82 


+0.78 


Average . 


13.1 


5.60 


256 


39 




6.75 


4.78 


0.29 


0.352 


0.570 


0.30 


5.08 


+0.51 


Jan. 18 


13.6 


5.70 


275 


30 


Acid 


6.80 


4.46 


0.22 


0.355 


0.398 


0.40 


4.86 


+0.84 


Jan. 19 


13.6 


5.70 


210 


44 


Acid 


6.80 


4.32 


0.24 


0.346 


0.382 


0.40 


4.72 


+0.98 


Jan. 20 


13.6 


5.70 


310 


20 


Acid 


6.70 


4.58 


0.22 


0.364 


0.361 


0.40 


4.98 


+0.72 


Jan. 21 


13.5 


5.70 


300 


39 


Acid 


6.80 


4.92 


0.21 


0.355 


0.474 


0.40 


5.32 


+0.38 


Jan. 22 


13.5 


5.70 


250 


35 


Acid 


6.70 


4.49 


0.24 


0.311 


0.362 


0.40 


4.89 


+0.81 


Jan. 23 


13.4 


5.70 


300 


39 


Acid 


6.90 


5.12 


0.23 


0.337 


0.463 


0.40 


5.52 


+0.18 


Jan. 24 


13.4 


5.70 


300 


39 


Acid 


6.90 


5.51 


0.22 


0.326 


0.405 


0.40 


5.91 


-0.21 


Average . 


13.5 


5.70 


278 


35 




6.80 


4.77 


0.22 


0.342 


0.406 


0.40 


5.47 


+0.53 



* Diet: raw beef heart, 200 gm. ; lard, 60 gm. ; augar, 60 gm. 
t Expressed as negative logarithms. 



METABOLISM STUDIES ON THE DOG 187 

neutral fat content in the fa s ces, though what relation there 
may be between tins and the dislike of fat is not evident. 
The practical result of this loss of weight after splenectomy 
was a moderate retention of nitrogen in the first post- 
splenectomy metabolism period. However, in the third 
period, when the animal had returned to exactly the same 
weight as before operation, nitrogen equilibrium was again 
maintained. It would seem conclusive, therefore, that the 
loss of weight and nitrogen retention of the earlier periods 
were due to an influence other than the absence of the 
spleen. It is of interest that this dog excreted no creatine. 

In the experiments thus far presented there is no evi- 
dence that the absence of the spleen influences in any way 
nitrogen metabolism. In a fourth animal, however, the 
results were discordant. 

This animal (Table LI) had served as a control for 
the blood counts of the three animals discussed above, and 
up to the time of our f oreperiod had been for twelve weeks 
on an adequate constant diet, as was the case in the other 
animals. Like Dog 52, this animal received boiled meat 
as a part of the dietary. The effect of splenectomy on 
the nitrogen metabolism, ten days after the operation, 
was very slight, but a nitrogen equilibrium of +0.48 gm. 
per day was changed to one of — 0.18 gm., figures not 
beyond the range of normal variations, but which, in the 
light of changes to be discussed later, are suggestive of the 
influence of anaemia. At a later period, three months after 
splenectomy, the animal had not regained the slight loss 
(0.5 kilo.) in weight, but it appeared to be in excellent 
condition and the ansemia, which had existed for several 
months, was improving. The plus balance of 1.10 gm. of 
nitrogen per day (upon a slightly higher nitrogen intake) 



188 



THE SPLEEN AND ANAEMIA 



TABLE L 



Dog 



52. Nitrogen Metabolism Before and Two, 
After Splenectomy 



Six, and Ten Weeks 





to 


* 
o 
cs 

.3 


Urine 


"3 

O 

Eh 


-a 
a 

V 

a 
'(- 

3 m 




Date 


3 
O 

a 
< 


o 

° 2 

m 


o 

Is 
IS 

©•a 


O 


"3 

O 

H 


ft 

'3 

o 

a 

6 

< 


o 

.S 
'a 

oS 

l-t 
O 


<D 

.2 

"•+2 

03 
<D 

u 

O 


© 

a 
"3 




kg. 




cc. 


10 






gm. 


gm. 


gm. 


gm. 


gm. 


gm. 




Nov. 25 


10.8 


4.77 


170 


44 


Acid 


6.50 


4.17 


0.30 


0.368 None 


0.38 


4.58 


+0.22 


Nov. 26 


10.8 


4.77 


160 


44 


Acid 


6.50 


4.23 


0.26 


0.378 None 


0.38 


4.61 


+0.16 


Nov. 27 


10.8 


4.77 


225 


33 


Acid 


6.50 


4.49 


0.23 


0.368 


None 


0.38 


4.87 


-0.10 


Nov. 28 


10.8 


4.77 


170 


58 


Acid 


6.50 


4.55 


0.24 


0.368 None 


0.38 


4.93 


-0.16 


Nov. 29 


10.8 


4.77 


180 


46 


Acid 


6.50 


4.55 


0.25 


0.368 None 


0.38 


4.93 


-0.16 


Nov. 30 


10.8 


4.77 


215 


40 


Acid 


6.50 


4.68 


0.25 


0.358 


None 


0.38 


5.06 


-0.29 


Dec. 1 


10.8 


4.77 


160 


43 


Acid 


6.50 


4.44 


0.25 


0.351 


None 


0.38 


4.82 


-0.05 


Average . 


10.8 


4.77 


183 


44 




6.50 


4.44 


0.25 


0.365 




0.38 


4.82 


-0.05 


Dec. 2 


Splenectomy 


Dec. 15 


9.4 


4.70 


225 


23 


Acid 


6.90 


2.75 


0.16 


0.213 


None 


0.44 


3.19 


+1.51 


Dec. 16 


9.4 


4.70 


180 


39 


Acid 


6.50 


3.73 


0.25 


0.324 


None 


0.44 


4.17 


+0.53 


Dec. 17 


9.5 


4.70 


115 


43 


Acid 


6.80 


2.99 


0.15 


0.281 


None 


0.44 


3.43 


+ 1.27 


Dec. 18 


9.5 


4.70 


210 


35 


Acid 


6.80 


2.79 


0.15 


0.289 


None 


0.44 


3.23 


+1.47 


Dec. 19 


9.6 


4.70 


85 


53 


Acid 


6.50 


2.48 


0.20 


0.295 


None 


0.44 


2.92 


+1.78 


Dec. 20 


9.7 


4.70 


275 


20 


Acid 


6.70 


2.79 


0.25 


0.291 


None 


0.44 


3.23 


+ 1.47 


Dec. 21 


9.8 


4.70 


175 


30 


Acid 


6.70 


2.52 


0.23 


0.289 


None 


0.44 


2.96 


+ 1.74 


Dec. 22 


9.8 


4.70 


225 


25 


Acid 


6.80 


2.88 


0.25 


0.311 


None 


0.44 


3.32 


+1.38 


Average . 


9.6 


4.70 


186 


34 




6.71 


2.87 


0.21 


0.287 




0.44 


3.31 


+1.39 


Jan. 12 


10.3 


4.40 


235 


28 


Acid 


6.00 


3.33 


0.27 


0.311 


None 


0.4S 


3.81 


+0.59 


Jan. 13 


10.3 


4.40 


190 


35 


Acid 


6.30 


3.38 


0.24 


0.311 


None 


0.48 


3.86 


+0.54 


Jan. 14 


10.3 


4.40 


210 


35 


Acid 


6.15 


3.60 


0.26 


0.311 


None 


0.48 


4.08 


+0.32 


Jan. 15 


10.4 


4.40 


180 


42 


Acid 


6.30 


3.45 


0.22 


0.324 


None 


0.48 


3.93 


+0.47 


Jan. 16 


10.4 


4.40 


175 


39 


Acid 


6.30 


3.54 


0.25 


0.324 


None 


0.48 


4.02 


+0.38 


Jan. 17 


10.4 


4.40 


225 


35 


Acid 


6.70 


3.38 


0.25 


0.311 


None 


0.48 


3.86 


+0.54 


Jan. 18 


10.4 


4.40 


205 


29 


Acid 


6.30 


3.57 


0.26 


0.311 


None 


0.48 


4.05 


+0.35 


Average . 


10-35 


4.40 


203 


35 




6.29 


3.46 


0.25 


0.318 




0.48 


3.94 


+0.45 


Feb. 10 


10,8 


4.10 


160 


35 


Acid 


6.90 


2.96 


0.23 


0.225 


None 


0.44 


3.40 


+0.70 


Feb. 11 


10.8 


4.10 


215 


25 


Acid 


6.80 


3.11 


0.25 


0.228 


None 


0.44 


3.55 


+0.55 


Feb. 12 


10.8 


4.10 


220 


22 


Acid 


6.80 


3.23 


0.20 


0.234 


None 


0.44 


3.67 


+0.43 


Feb. 13 


10.8 


4.10 


200 


27 


Acid 


6.80 


3.20 


0.19 


0.234 


None 


0.44 


3.64 


+0.46 


Feb. 14 


10.9 


4.10 


190 


32 


Acid 


6.80 


3.44 


0.18 


0.231 


None 


0.44 


3.88 


+0.22 


Average . 


10.8 


4.10 


197 


28 




6.82 


3.19 


0.21 


0.230 




0.44 


3.63 


+0.47 



* Diet: boiled beef heart, 100 gm.; lard, 50 gm.; sugar, 50 gm. 
t Expressed as negative logarithms. 



METABOLISM STUDIES ON THE DOG 



189 



in this period, without change in weight, suggests the pos- 
sibility of the utilization of this nitrogen for the repair of 
the anaemia. Utilization of protein was not disturbed, 

TABLE LI 

Dog 56. Nitrogen MetabolisxM Before and Ten Days and Three Months 

After Splenectomy 





'53 


* 

9 
M 

a 

.9 


Urine. 


Q 

<£ 
3 
S 

& 


T3 

a 

m 

<o 
a 

3 as 




Date 


"3 

3 
O 

s 


o 
*1 


°3 


§1 

«j -t-> 

.2 a 

4) 


o 


•a 

o 

3 

a 


o 

a 
[s 

"3 

o 
c 


o 
a 


<0 

a 

M 

-a 




fes 


£ 


< 


* & 


& 


M ° 


H 


< 


O 


O 


pE| 


^ ' 


Z 




kg. 




cc. 


10 






gm. 


gm. 


gm. 


gm. 


gm. 






Feb. 16 


8.5 


3.43 


100 


39 


Acid 


6.30 


2.63 


0.13 


0.221 


0.014 


0.35 


2.98 


+0.45 


Feb. 17 


8.5 


3.43 


115 


44 


Acid 


6.00 


2.61 


0.17 


0.2700.022 


0.35 


2.96 


+0.47 


Feb. 18 


8.5 


3.43 


140 


38 


Acid 


6.13 


2.39 


0.14 


0.2790.022 


0.35 


2.74 


+0.66 


Feb. 19 


8.4 


3.43 


120 


42 


Acid 


6.30 


2.63 


0.17 


0.319:0.057 


0.35 


2.98 


+0.45 


Feb. 20 


8.4 


3.43 


120 


47 


Acid 


6.30 


2.73 


0.16 0.26110.116 


0.35 


3.08 


+0.35 


Feb. 21 


8.4 


3.43 


200 


39 


Acid 


6.30 


2.61 


0.13:0.2650.084 


0.35 


2.96 


+0.47 


Feb. 22 


8.4 


3.43 


90 


50 


Acid 


6.15 


2.60 0.14 0.2530.067 


0.35 


2.95 


+0.48 


Average . 


8.4 


3.43 


126 


43 




6.21 


2.60! 0.15 !o.2670.055 


0.35 


2.95 


+0.48 


Feb. 23 


Splenectomy 


Mar. 5 


8.0 


3.37 


165 


47 


Acid 


6.15 


3.11 


0.13 


0.2310.12110.41 


3.52 


-0.15 


Mar. 6 


8.0 


3.37 


110 


46 


Acid 


6.15 


3.00 


0.14 


0.213 0.143! 0.41 


3.41 


-0.04 


Mar. 7 


8.0 


3.37 


150 


44 


Acid 


6.50 


3.19 


0.14 


0.23410.081 


0.41 


3.60 


-0.04 


Mar. 8 


8.0 


3.37 


210 


40 


Acid 


6.15 


3.30 


0.16 0.22110.119 


0.41 


3.71 


-0.34 


Mar. 9 


7.9 


3.37 


170 


42 


Acid 


6.15 


3.32 


0.16 0.213J0.144 


0.41 


3.73 


-0.36 


Mar. 10 


7.9 


3.37 


130 


49 


Acid 


5.85 


3.18 


0.16 


0.213 


0.114 


0.41 


3.59 


-0.22 


Mar. 11 


7.9 


3.37 


170 


38 


Acid 


6.15 


3.09 


0.12 


0.213 


0.129 


0.41 


3.50 


-0.13 


Average . 


8.0 


3.37 


152 


44 




6.14 


3.17 


0.14 


0.220 


0.122 


0.41 


3.72 


-0.18 


May 20 


7.9 


3.78 


130 




Acid 




2.17 




0.213 


0.029 


0.38 


2.55 


+ 1.23 


May 21 


7.9 


3.78 


145 




Acid 




2.07 




0.213 


0.014 


0.38 


2.45 


+ 1.33 


May 22 


7.9 


3.78 


130 




Acid 




2.24 




0.2250.010 


0.38 


2.62 


+1.16 


May 23 


7.9 


3.78 


260 




Acid 




2.56 




0.2380.017 


0.38 


2.94 


+0.84 


May 24 


7.9 


3.78 


115 




Acid 




2.47 




0.2130.014 


0.38 


2.85 


+0.93 


Average. 


7.9 


3.78 


156 








2.30 


0.220'0.017 


0.38 


2.68 


+ 1.10 



* Diet: boiled beef heart, 75 gm.; lard, 40 gm.; sugar, 40 gm. 
t Expressed as negative logarithms. 



being 90 per cent, in Period I, 88 per cent, in Period II, 
and 90 per cent, in Period III. 

Unlike the other three dogs, we had here in Period II 
an increase of creatine amounting to 45 per cent. This 



190 



THE SPLEEN AND ANEMIA 



increase was at the expense of the creatinine, however, 
for the total creatinine, including preformed creatinine and 
creatine as creatinine, agrees very closely, in the two periods, 
amounting to 0.314 gm. in the foreperiod and 0.325 gm. in 
the after-period. 









TABLE LII 










Fat Determinations Before 


and After Splenectomy 




Dog 
No. 


Period * 


Total 
intake 


Total 
output 


Fat 
utilized 


Total out- 
put of fatty 
acids in- 
cluding 
soaps 


Fatty acids 
in total 
output 


Total 

output 

neutral 

fats 


Neutral 
fat in 
total 

output 






gm. 


gm. 


per cent. 


gm. 


per cent. 


gm. 


per cent. 


48 


I 

(7 days) 


460.6 


26.54 


94.2 


22.45 


84.4 


4.09 


15.6 




Nov. 24 


Splenectomy 














II 


460.6 


20.92 


95.5 


18.11 


86.5 


2.81 


13.5 




(7 days) 


















III 


460.6 


15.77 


96.6 


11.51 


73.0 


4.26 


27.0 




(7 days) 
















52 


I 

(7 days) 


374.8 


9.19 


97.5 


6.29 


68.4 


2.90 


31.6 




Dec. 2 


Splenectomy 














II 


428.32 


12.64 


97.0 


5.93 


46.9 


6.71 


53.1 




(8 days) 


















III 


374.8 


17.14 


95.4 


8.44 


49.2 


8.70 


50.8 




(7 days) 


















IV 


267.7 


7.85 


97.1 


6.71 


85.5 


1.14 


14.5 




(5 days) 
















56 


I 

(7 days) 


298.4 


13.59 


95.4 


9.27 


68.3 


4.32 


31.7 




Feb. 23 


Splenectomy 














II 


298.4 


14.25 


95.2 


11.11 


78.0 


3.14 


22.0 




(7 days) 
















57 


I 

(7 days) 


380.45 


23.87 


93.7 


19.42 


81.4 


5.04 


18.6 




Mar. 7 


Splenectomy 














II 


380.45 | 10.56 


97.2 


7.68 


72.7 


2.88 


27.3 




(7 days) 


1 













* These periods correspond exactly to those in Tables I, II, III, and IV. 

During Period III, while the average creatine output 
was exactly the same as during Period II, the creatine out- 
put fell to a figure lower than either of the preceding 
periods. The variation in the partition of creatine and 
creatinine in this animal we are unable to explain. 



METABOLISM STUDIES ON THE DOG 



191 



Fat Utilization. — The utilization of fat (Table LII) 
in all the animals was normal in all periods. The partition 
of fatty acids (including soaps) and neutral fats shows 
some variation, especially in Dog 52, hut to this we are 
inclined to ascribe no importance. A thorough search of 
the literature shows that no studies of fat utilization in 
animals before and after splenectomy have previously 
been made. 

Iron Metabolism. — As has been shown elsewhere (see 
p. 119) , Dogs 57, 48, and 52 showed no important change in 
the elimination of iron after splenectomy, while Dog 56 did. 



Discussion 

These observations show that in three of four animals 
the removal of the spleen had no effect upon nitrogen 



TABLE LIII 
Blood Examinations 



Dog No. 


Period * 


Haemoglobin 


Red cell count 


48 


I 

II 

III 


per cent. 

100 
104 
100 


5,900,000 
5,570,000 
5,540,000 


52 


I 

II 

III 

IV 


105 

106 

84 

90 


6,700,000 
6,840,000 
5,360,000 
5,100,000 


56 


Initial 
I 

II 
III 


105 

83 
70 

72 


6,450,000 
6,020,000 
5,890,000 
4,950,000 


57 


I 
II 


95 
90 


6,130,000 
6,130,000 



* The periods correspond exactly to those of the previous tables 

metabolism, the utilization of fat, or the elimination of 
iron, and justifies the conclusion that the removal of the 



192 THE SPLEEN AND ANAEMIA 

normal spleen in a normal animal has no important effect 
upon general metabolism. It is necessary, however, in 
order that there may be no question about this conclusion, 
to explain the discordant results in the fourth animal 
(Dog 56). This animal showed a loss of weight, an 
increased elimination of iron (see p. 119) , and a disturbance 
of creatine metabolism. The fat metabolism was unaltered. 
The question arises whether these changes are due to the 
absence of the spleen or to the anaemia which was present. 
In Table LIII are presented the blood examinations of 
each dog at the time of the several metabolism periods. 

It will be seen that Dogs 48 and 57 showed no apprecia- 
able change in the blood picture after splenectomy, but 
that Dogs 52 and 56 did. The blood changes in Dog 52, 
however, were relatively slight. The situation in regard to 
Dog 56 was somewhat different. This animal had been 
placed on a constant diet, the chief article of which was 
boiled beef -heart, twelve weeks before the first metabolism 
study. At that time the blood examination showed haemo- 
globin 105 per cent, and red cells 6,450,000. At the time 
of our presplenectomy period it showed a relatively low 
haemoglobin content (83 per cent.) and 6,020,000 red cells. 
After splenectomy the haemoglobin continued to fall until, 
two and a half months after operation, it showed the low 
level of haemoglobin 60 per cent, and red cells 4,560,000. 
It is evident, therefore, that this animal differed from 
the other three in that it developed an anaemia more rapidly 
and eventually of a more severe grade than was the case in 
any other animal of this series. As we have shown else- 
where, anaemia of varying severity is a fairly constant result 
of splenectomy in the dog. The anaemia may be slight, 
as in Dog 52, or more severe, as in Dog 56, and may, as 



METABOLISM STUDIES ON THE DOG 193 

has been suggested, be lessened by diet. The influence of 
diet we have already discussed, but it is not a matter which 
concerns us at the present time (see p. 22). The essential 
fact is that Dog 56 developed a severe anaemia, already 
progressive at the time of the first metabolism study, while 
Dogs 48 and 51 were not anaemic, and Dog 52 showed only 
a slight non-progressive deterioration of the blood. The 
question naturally arises: Is the increased elimination of 
iron and the disturbance of the creatine metabolism due 
to the anaemia and not to an influence on metabolism con- 
sequent upon the absence of the spleen? 

A few words are necessary concerning Richet's state- 
ment that the splenectomized dog requires more food to 
maintain its weight than does the normal dog. In view 
of our results, Richet's conclusion is not tenable. Dog 57 
(Table XLVIII) maintained its presplenectomy weight 
without change in diet and with only a slight change in the 
nitrogen balance. Dog 48 (Table XLIX) likewise showed 
only a trifling change during the three weeks after opera- 
tion and a return to the previous weight after seven to 
eight weeks. The serious loss of weight in Dog 52 was 
due to loss of appetite, and that, relatively slight, in Dog 56 
was complicated by the coexisting anaemia. 

Moreover, during the past five years we have fre- 
quently noticed a tendency for splenectomized dogs to 
become obese, and this tendency is mentioned also by 
several investigators who have studied splenectomized ani- 
mals for long periods of time. This tendency to put on 
weight is strikingly shown by two of the dogs (48 and 52) 
of this series. At the close of the metabolism work, pre- 
sented in Tables XLIX and L, these animals were not 
destroyed, on account of the possible necessity of repeating 

13 



194 THE SPLEEN AND ANEMIA 

the metabolism studies after longer periods had elapsed. 
The change from a special to the ordinary kennel diet 
("table scraps") led to a rapid increase of weight in 
each instance; in three months the weight of Dog 48 in- 
creased from 13.4 to 15.8 kilos., while in two months 
Dog 52 rose from 10.9 to 12.9 kilos. 

Our results are therefore in accord with those of Paton 
rather than with those of Richet, and demonstrate that in 
the absence of anaemia the removal of the spleen has no 
influence upon nitrogen or fat metabolism, and in all prob- 
ability no influence upon iron elimination. 

Our general results may be summarized as follows : 

Four dogs have been subjected to metabolism studies 
before splenectomy and at intervals of three days to three 
months after splenectomy. In three of the four animals 
the removal of the spleen was not followed by any dis- 
turbance of nitrogen metabolism, fat utilization, or iron 
elimination. Two of these animals showed no anaemia, and 
the third only a slight reduction in haemoglobin and num- 
ber of red cells. 

A fourth animal, studied ten days and three months 
after splenectomy, developed eventually a definitely pro- 
gressive anaemia of moderate severity. This animal showed 
a slight loss of weight, a slight disturbance of nitrogen 
balance, and of creatine-creatinine partition, with a marked 
increase in the elimination of iron. We conclude, there- 
fore, that, under the conditions of our experiments, there 
is no evidence that the spleen has an influence on metab- 
olism, and we regard the disturbances occurring in one of 
our dogs as due to the coexisting anaemia and not to the 
absence of the spleen. 



CHAPTER IX 

GENERAL SUMMARY OF EXPERIMENTAL STUDIES 

After splenectomy in dogs three prominent phe- 
nomena are observed: 

1. An anaemia of the secondary type, mild or moderate 
in character, which usually reaches its severest stage after 
one and a half months and is followed by repair, which is 
well advanced after three or four months but may not be 
complete for longer periods of time. 

2. An increased resistance of the red blood-cells to 
hypotonic salt solutions, hemolytic serum, saponin and 
cobra venom, and mechanical shaking. 

3. A lessened tendency to hemoglobinuria and jaun- 
dice, and sometimes an absence of jaundice, after the ad- 
ministration of hemolytic agents. 

The anemia may be irregular in its onset and severity, 
as may be also the repair process, but as a rule it has a very 
definite course. The decrease in haemoglobin content 
occurs usually a little later and is often slightly more 
marked than the decrease in red blood-cells. The former 
seldom falls below 55 per cent, or the latter below 3,000,- 
000. Neither during the period of ansemia nor repair do 
nucleated or other abnormal types of cell appear in the 
peripheral blood, except occasionally, at the time of begin- 
ning repair. The behavior of the white cells is quite con- 
stant; shortly after operation a marked rise to 26,000 to 
38,000 occurs, with a return after a few days to 20,000 
and a gradual decrease to normal level after one to four 
months. The increase in leucocytes is almost entirely an 

195 



196 THE SPLEEN AND ANEMIA 

increase in the polymorphonuclear type, the lymphocytes 
later showing a slight increase. The behavior of the 
eosinophiles is inconstant. 

The " blood crisis," so frequently found after removal 
of the human spleen in splenic disease, is not present after 
the removal of the normal dog's spleen. 

Dietary studies indicate that the anaemia is not influ- 
enced by the amount of iron furnished in the food. On the 
other hand, a small number of experiments furnish some 
evidence that the anaemia is apt to be more severe when 
the animal is fed on cooked food than when it is fed on an 
uncooked diet. Control experiments, in which other opera- 
tive procedures, such as unilateral nephrectomy, have pre- 
ceded splenectomy, prove conclusively that it is the absence 
of the spleen, and not post-operative accidents or compli- 
cations, that is the essential factor in the production of 
anaemia. 

A review of the literature of splenectomy in man shows 
that after removal of the spleen for injury or simple lesion 
not involving a disturbance of the function of the spleen, 
as rupture, twist, and cyst, a mild anaemia of variable course 
is the rule, and that in the absence of the spleen the repair 
of anaemia is delayed. 

The increased resistance of the red blood-cells is a 
property of the red cell itself and is not due to an anti- 
haemolytic power of the serum or to changes in comple- 
ment content. The exact reason of this increased resist- 
ance is not evident. Its association with anaemia and the 
concomitant repair suggests that the presence of young 
and more resistant cells might explain it. We have not 
been able, however, to demonstrate an increase in nucleated 
cells or in the reticulated cells, usually considered as young 
forms indicative of active blood formation and more resist- 



SUMMARY OF EXPERIMENTAL STUDIES 197 

ant to lytic agents. We believe, however, that the in- 
creased resistance of the red cells is not dependent merely 
on the absence of the spleen, but is, in part at least, in 
some way associated with the anaemia, or the factor or 
factors causing it, thus differing, in our view, from Eanti 
and his associates. 

In regard to the decreased tendency to hemoglobin- 
uria and jaundice after the administration of hemolytic 
agents, we offer experimental evidence to indicate that ( 1 ) 
absence of the spleen does not prevent the secretion of bile ; 
(2) the spleen does not influence the transformation of free 
haemoglobin into bile-pigment, and (3) that fresh splenic 
extracts have no demonstrable action in vitro. Two im- 
portant factors appear to be (a) the influence of anemia, 
and (b) the increased resistance of the red cells, in that 
each reduces the amount of hemoglobin set free. The most 
important factor, and a purely mechanical one, concerns 
the way in wmich the hemoglobin set free by blood de- 
struction reaches the liver. Under normal conditions the 
disintegrating blood-cells accumulate in the spleen and the 
liberated hemoglobin normally reaches the liver directly 
and in concentrated form through the portal vein, and, as 
a result, hemoglobinuria and jaundice are more apt to 
occur. In the absence of the spleen it reaches the liver 
through the general circulation (hepatic artery) more 
slowly and much diluted, and hemoglobinuria is therefore 
less frequent and jaundice is of less degree or entirely 
absent. Our experiments in which injections of hemoglo- 
bin into the mesenteric vein were contrasted with in j ections 
-of hemoglobin into the femoral vein offer conclusive proof 
of the correctness of this view, as do also experiments in 
which, by means of an Eck fistula and by anastomosis of 
the splenic vein with the vena cava, the splenic blood was 



198 THE SPLEEN AND ANAEMIA 

diverted from the liver without removal of the spleen. 
Another important mechanical factor connected with the 
blood supply to the liver is that in splenectomized animals 
the total volume of the portal blood supply is consider- 
ably lessened. Further support of this view is found in 
the anaemia that followed ligation of the splenic veins and 
in the single experiment where the mesenteric vein was 
unwittingly transplanted into the vena cava. 

Another factor which we have discussed in this con- 
nection is that concerning the influence of fatty acids as 
brought forth by Joannovics and Pick. Their views are 
supported by Eppinger and King, who find, after sple- 
nectomy in the dog, a decrease in the unsaturated fatty 
acids and an increase in the cholesterin content of the blood, 
changes which might well have an influence on the degree 
and velocity of haemolysis. Their observations, unfortu- 
nately, we cannot confirm. 

In regard to the problem of the anaemia, detailed com- 
parison of the arterial and venous blood of the spleen 
offers no evidence to indicate, by the methods used, that the 
spleen has an important role in blood formation, or, on 
the other hand, that it is appreciably active in blood 
destruction. 

The injection, however, into normal dogs of fresh 
spleen extract does cause an evanescent but definite in- 
crease in haemoglobin and red-cell content, which is not 
caused by extracts of other organs. This result would 
appear to be brought about through a stimulating action 
on the bone-marrow. On the other hand, fresh beef spleen 
fed liberally to splenectomized dogs does not prevent the 
occurrence of anaemia. 

If in splenectomized dogs which have recovered from the 



SUMMARY OF EXPERIMENTAL STUDIES 199 

anaemia following removal of the spleen a second anaemia 
is produced by administering some haemolytic agent, this 
anaemia, as shown by direct blood examination, runs a 
longer course and has a longer period of repair than is the 
case in the normal dog. Here we have an apparent para- 
dox, for, as has been pointed out above, the red cells of 
the splenectomized animal are more resistant to haemo- 
lytic agents than are those of the normal dog, and theo- 
retically one would expect a mild anaemia of shorter course 
with quick repair. 

Our explanation of the paradox is that in the spleenless 
dog some factor is at work, due to the absence of the spleen, 
which prevents rapid blood regeneration. The normal 
dog, though suffering as great, or even a greater, blood 
destruction, has no fault in regeneration, and its blood re- 
turns quickly to normal. On the other hand, in the splenec- 
tomized dog the factor delaying regeneration operates 
after an acute anaemia, as it did originally after removal 
of the spleen, and therefore the anaemia often reaches a 
lower level and is repaired more slowly. 

Experiments undertaken to show that this unknown 
factor might be a function of the spleen concerned in the 
utilization of iron for the manufacture of haemoglobin 
have given negative results. Occasionally, shortly after 
splenectomy, a slight increase in elimination of iron was 
observed, but we have found no evidence of disturbance 
of iron metabolism one, nine, and twenty months after 
splenectomy. The most marked disturbance of iron meta- 
bolism occurred in a dog with a moderately severe anaemia, 
and we believe that an increased elimination of iron is a 
manifestation of increased blood destruction and not di- 
rectly dependent on the absence of the spleen. 



200 THE SPLEEN AND ANEMIA 

Control studies, in which without removal of the spleen 
the splenic blood was diverted from the liver by means 
of an Eck fistula or an anastomosis of the splenic vein 
with the vena cava or ligation of the splenic vein, yielded 
results similar to those following splenectomy, but varying 
somewhat in degree or duration. The anaemia and the 
icterus, as also the slow repair of anaemia, under these 
circumstances did not differ greatly from the results 
following splenectomy. If the anaemia is due to the loss 
of a stimulating action on the bone-marrow, these experi- 
ments show that access to the liver is necessary for the 
activation of such stimulant. The increased resistance 
of the red cells, on the other hand, did not persist for so 
long a time as after splenectomy. The lessened tendency 
to jaundice, on account of the important mechanical factor 
involved, was quite similar to that following splenectomy. 
These observations emphasize the importance of the 
mechanical factor (the disturbance of the direct blood flow 
to the liver) , and suggest, also, some functional relation of 
the spleen to the liver that is not yet fully understood. 

Studies of the bone^marrow after splenectomy show 
that, as a rule, the fatty marrow of the long bone is trans- 
formed into red marrow. During the early months this 
change is slight or absent, but after six to twenty months 
it is fairly constant and complete. There is no evidence 
that this change is compensatory to the early anaemia 
caused by splenectomy or to an increased haemolysis in the 
lymph nodes. It may be that it is a concomitant of the 
activity of the bone-marrow in taking over, in the absence 
of the spleen, the function of storing and elaborating the 
iron of old blood-pigment, but our observations do not fully 
support this hypothesis. 



SUMMARY OF EXPERIMENTAL STUDIES 201 

The lymph-nodes, after splenectomy, exhibit, as a rule, 
a great increase in the number of endothelial cells. l\\ 
most splenectomized dogs that succumb to a hemolytic 
agent within forty-eight hours the sinuses of the lymph- 
nodes contain large numbers of endothelial cells filled with 
red blood-corpuscles. This is seen, also, to a less extent 
in the case of the stellate cells of the liver capillaries. This 
phenomenon has not been seen to the same extent in normal 
dogs receiving hsemolytic serum. Such findings suggest 
that in the absence of the spleen the function of forming 
red-blood-cell-phagocytic cells — normally a minor func- 
tion of the lymph-nodes — becomes highly developed in 
these structures and is shared also by the liver, and that 
in times of stress, as after excessive blood destruction, 
these organs assume, in part at least, the function of 
destroying red blood-cells by phagocytosis. The small 
iron content of the lymph-nodes and liver indicates, how- 
ever, that under normal circumstances, in the splenecto- 
mized animal, no excessive destruction of this type occurs. 

Detailed metabolic studies have demonstrated conclu- 
sively that the removal of the normal spleen in a normal 
animal has no effect on nitrogen, fat, or iron metabolism. 
When disturbance of nitrogen and iron metabolism occurs 
it is due, in all probability, to a coexistent ansemia, and 
not to the mere absence of the spleen. 

In conclusion, we wish to state frankly that, while the 
experiments here described add to our knowledge of cer- 
tain phases of the relation of the spleen to blood destruc- 
tion and regeneration, we are still in doubt about the exact 
cause of (a) the ansemia and (b) the increased resistance 
of the red cells which so constantly follows splenectomy. 



CHAPTER X 

METABOLISM STUDIES ON MAN BEFORE AND AFTER 
SPLENECTOMY 

Studies of metabolism after splenectomy in the normal 
dog, as has been shown in the preceding chapter, are es- 
sentially negative. In man the situation is entirely differ- 
ent. Splenectomy, for chronic disease at least, is done in 
the presence of an anaemia of more or less severity, and 
the alterations in metabolism before operation are largely 
those dependent on the changes in the blood. The im- 
provement following splenectomy is to be regarded, there- 
fore, not as dependent on the removal of a normal function 
of the spleen, but as dependent on the removal of a hsemo- 
lytie or other toxic activity for which the altered physiology 
of the spleen is responsible. Metabolism studies in man, 
under such conditions, thus become valuable adjuvants 
to the blood examination in determining the type of splenic 
disease or anaemia in which favorable results from splenec- 
tomy may be expected. 

As investigations of this type are comparatively new — 
to our knowledge only five studies of conditions both before 
and after splenectomy have been made — we present in con- 
siderable detail two carried out under our direction: one 
in connection with congenital hemolytic jaundice 150 and 
the other in connection with pernicious anaamia. 342 

In Congenital Hemolytic Jaundice 
The subject of the first of these was a child suffering 
from congenital haemolytic jaundice presenting the fol- 
lowing history: 

202 



METABOLISM STUDIES ON MAN 203 

At birth, at term, the child weighed seven pounds, and 
is described as lacking the characteristic red color of the 
newly bom. About twenty-four hours after birth the 
" alabaster whiteness " of the skin, which the mother de- 
scribed, changed to a mahogany brown, which lasted three 
months, gradually fading to a sallow pallor, which has 
persisted. At six months, when the child passed through 
an attack of pneumonia, it weighed only ten pounds. The 
general health was poor and gastro-intestinal disturbances 
frequent. In the fourteenth month the first severe anaemia, 
accompanied by dark-brown discolorations of the skin and 
preceded by protracted vomiting and diarrhoea, was ob- 
served. Two months later a similar attack occurred, with 
the new feature of marked oedema of the entire body. 
During these attacks the rectal temperature usually rose 
to 104 or 105. Periods of recrudescence and exacerbation 
followed one another until the child was two and one-half 
years old, when an unusually severe attack kept him in 
bed for five months. Vomiting and diarrhoea were severe, 
and hemorrhages from the nose and bowel were frequent 
and difficult to control. During the second month of this 
period a partial paralysis of the left side developed. At 
this time an injection of neosalvarsan was given, more for 
the hsematinic action of the arsenic than with any suspicion 
of lues. Gradual improvement followed this treatment, 
and after the paralysis had disappeared, except for a resid- 
ual spastic palsy of the left leg, the child enjoyed fairly 
good health. The Wassermann reaction, frequently re- 
peated, has always been negative. During the eight 
months following this attack salvarsan was given five times 
by rectum. About the time he was five years old, and 
again seven months later, he lost the power of speech, was 



204 THE SPLEEN AND ANAEMIA 

more or less delirious, and complained of pain in his head. 
At three and one-half and again at four and one-half years 
he had an otitis media. His appetite has always been poor, 
never normal, and at times he refuses to eat. A tendency 
to localized oedema, especially of the face and of the hand, 
has been constantly noted. He tires easily, and frequently 
complains of this. Obstinate constipation has been the 
rule, and the faeces are described as dark or orange in color. 

From the family history it is found that a sister was 
jaundiced for ten days and a brother for two days after 
birth, but these children, now fifteen and thirteen years 
of age respectively, have otherwise been in good health. 
The father is said to have had an enlarged spleen and 
offers a history of exposure to lues, of skin eruption, and 
chronic abscess of joint and ankle. The mother, three 
months before the birth of the subject of the present study, 
was paralyzed and suffered a separation of the pelvic 
bones. The delivery was under anaesthesia. 

Laboratory Examinations. — An examination of the 
numerous clinical records which have accumulated shows 
that the urine offers nothing of unusual interest. The only 
positive finding is an occasionally slight trace of albumin. 
Tests for bile have always been negative, and urobilin 
tests have shown no increase of this substance. Examina- 
tions of the faeces indicate that food is well digested ; tests 
for occult blood have been negative, and no parasites or 
ova have been found. No records of the early blood exam- 
inations have been preserved, except a brief record that at 
the time of the first severe attack (when fourteen months 
old) the haemoglobin fell to 24 per cent, and a diagnosis of 
pernicious anaemia was made. A number of counts made 
during the years 1913 and 1914 showed considerable varia- 



METABOLISM STUDIES ON MAN 205 

tion in both haemoglobin (from 65 per cent, to 28 per cent. ) 
and red blood-cells (4,180,000 to 1,300,000). The Brule 
test and tests for cross haemolysis with normal scrum and 
cells were negative. The subsequent blood counts are sum- 
marized in Table LIV. 

At the beginning (December 3, 1914) of our metab- 
olism studies a complete examination of the child was made, 
and from the notes at that time the following abstract of 
positive findings has been prepared: 

The boy is five and one-half years of age, 105.5 cm. in 
height, weighs 39 pounds, is well nourished and of good 
muscular development. His skin is slightly sallow, but 
there is no true jaundice. Over the vessels of the neck 
a systolic bruit is heard, and an occasional slight systolic 
whiff is heard at the apex of the heart. At the base of the 
heart the first sound is replaced by a systolic murmur of 
a blowing character, and the second sounds are accent- 
uated. Normal sounds are heard at the tricuspid area. 
The liver is doubtfully palpable. The splenic dulness be- 
gins in the mid-axillary line at the sixth rib and extends 
down a little below the line of the umbilicus; its greatest 
length is 18 cm. and its greatest width about 9 cm. The 
spleen feels firm, smooth, and without distinct notches. 
The right lower extremity is normal; the left lower ex- 
tremity normal as to thigh and leg, but the ankle and foot 
show a spastic paralysis. 

The urine at this time was amber in color, with no 
gross sediment; the specific gravity was 1.029; tests for 
albumin, sugar, acetone, diacetic acid, indican, and bili- 
rubin were negative. The test for urobilin gave a doubtful 
reaction; under the microscope some mucus was seen, but 
no cells, casts, or crystals. The blood count at this time 



206 



THE SPLEEN AND ANAEMIA 



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METABOLISM STUDIES ON MAN 207 

is given in Table LIV, under the date of December 3, 1914. 

The first metabolic period ran from the 4th to the 14th 
of December, and during this time there was little or no 
change in the patient's condition. Throughout the period 
there was a tendency to elevation of temperature, which, 
however, rose but once over 101. The child was not kept 
in bed, ate regularly, and required no medication or cathar- 
tic. At the end of the period he was discharged, to return 
after Christmas. 

During the interval at home (December 14, 1914, to 
(January 26, 1915) no noteworthy change in condition oc- 
curred. On January 26 the patient was readmitted to the 
University Hospital, service of Dr. Charles H. Frazier. 
Physical examination revealed nothing new; examination 
of the blood and urine showed but little change. On Jan- 
uary 28 the spleen was removed by Dr. Frazier, under 
ether anaesthesia. The operation was uneventful and there 
was only a trifling loss of blood. At the time of the opera- 
tion the coagulation time of the blood was found to be 
about four minutes, and tests for resistance of red cells 
showed beginning of haemolysis in 0.65 per cent, and com- 
plete haemolysis in 0.425 per cent, salt solution. Conva- 
lescence after the operation was satisfactory, and on Feb- 
ruary 4 the patient was transferred to the medical service, 
and the second period of metabolism study was started on 
February 5. At this time the child's weight was 40 pounds. 

On the fourth day of metabolism study an attack of 
bronchitis caused a rise of temperature to 103, and for two 
or three days there was some loss of appetite, and on the 
ninth day a mild otitis media developed. Despite these 
disturbances, the metabolism study was continued until the 
period of ten days representing the eighth to eighteenth 
days after splenectomy was completed. 



208 THE SPLEEN AND ANAJEMIA 

At the end of the period the child's weight was 3Sy 2 
pounds and he seemed considerably improved in color and 
strength. The appetite was good. The condition of the 
bowels demanded an occasional cathartic, which, however, 
never caused watery stools. Even before discharge on 
February 18, just three weeks after operation, it was evi- 
dent that a marked improvement in the blood picture had 
occurred, both haemoglobin and red blood-cell count being 
double that obtained on the first admission. 

After discharge the improvement continued steadily, 
with greatly increased appetite and strength. The skin 
lost its sallow hue and became normal in appearance. In 
the two months since operation the child has enjoyed 
uninterrupted good health, except for one attack of indi- 
gestion, the result of overfeeding. Two weeks previous 
to the last blood count given in the table a rather severe 
nasal hemorrhage occurred as a result of excoriations. The 
lowered haemoglobin in the last count is probably to be 
explained by this hemorrhage. 

Pathologic Description of the Spleen. — The 
weight is 640 gm. ; length, 18.3 cm. ; width, 10.8 cm. ; thick- 
ness, 3.8 at one end, increasing to 8.4 at opposite end. The 
organ is of uniform bluish-red color. The capsule is for 
the most part smooth, with a few fine adhesions at one 
pole, where there is also a small circumscribed area (1.5 
cm. in diameter) of thickening. The vessels of the hilum 
are normal. No supernumerary spleens are seen. 

On section a large amount of dark fluid blood escapes. 
The cut surface has a uniform smooth, glistening appear- 
ance of dull-red color. The Malpighian bodies are dis- 
tinctly visible, but not so large as in the normal spleen. 
The trabecular are not prominent. The consistence is 



METABOLISM STUDIES ON MAN 209 

increased, it being almost impossible to rupture the spleen 
by pressure with the thumb. At one end (the larger) 
of the organ is a distinctly circumscribed, but not encap- 
sulated, mass (3.5 cm. in diameter), spherical in shape, 
which shows no Malpighian bodies, but does present a few 
minute ochre-colored areas. This area is of the same 
color and consistence as the rest of the spleen. On section 
it bulges prominently above the cut surface. The weight 
of the spleen after escape of fluid blood from three longi- 
tudinal incisions is 435 gm. 

Gross Diagnosis. — Splenomegaly with area of recent 
infarction. 

Microscopic Appearance. — Very slight thickening of 
capsule with no increase of trabecular. The sinuses are 
dilated and congested. The reticulum is increased in 
amount, and the cells of pulp appear to be decreased in 
number. The Malpighian bodies show no change except a 
hyaline thickening of central arteries which is evident in 
arteries elsewhere. Macrophages are not numerous and 
deposition of pigment is not seen. 

The tumor-like mass described in notes on gross ap- 
pearance shows intense congestion and hemorrhage without 
evidence of cell destruction, and represents, in all proba- 
bility, the results of occlusion of blood-vesesls at time of 
operation. 

Histologic Diagnosis. — Congestion, increase of reti- 
culum, hyaline degeneration of arteries. ( The rather nega- 
tive histologic appearance is in general that described for 
splenomegaly with congenital hemolytic jaundice.) 

Methods of Metabolism Study. — The child was kept 
in a private room of the University Hospital, with a special 
metabolism nurse in attendance. The complete metab- 

14 



210 THE SPLEEN AND ANAEMIA 

olism study occupied one period of ten days and a supple- 
mentary period of five days before splenectomy, and a 
period of ten days after splenectomy. The first period 
extended from December 3 to December 14, after which 
the child went home for the Christmas holidays. While 
the child was at home a supplementary period of five days 
for the study of uric acid elimination extended from Janu- 
ary 20 to January 24. The return to the hospital was 
delayed on account of the desire of the attendant phy- 
sicians to improve, if possible, the blood picture and the 
general condition. On January 28, two days after re- 
admission, the spleen was removed, and on February 5, 
after a lapse of eight days, the post-splenectomy metab- 
olism studies were begun and continued for ten days. On 
account of the capricious appetite of the child, it was im- 
possible to adhere to a constant dietary, such as the Folin 
diet, and therefore considerable liberty was allowed. The 
intake was determined by weighing all foods taken and 
analyzing portions for nitrogen and fat. This policy was 
followed in both of the ten-day periods, but not in the 
supplementary five-day period when the child was at home. 
Despite the freedom as to diet, the food intake was quite 
constant in character from day to day, consisting, in the 
first period, essentially of milk, eggs, cereals, apple sauce, 
bread, crackers, potatoes, butter, sugar, rice, and tapioca. 
During the first five days of this period beef, chicken, or 
fish was allowed once a day; during the second five days 
these were entirely eliminated, as they were also in the 
supplementary period of five days before splenectomy and 
the ten-day period after splenectomy. Thus, except in the 
first five-day period, the child was on a practically purin- 
and creatin-free diet. The calorific value of the diet was 



METABOLISM STUDIES ON MAN 211 

adequate. During Periods I and II (Table LV) the sub- 
ject received approximately 1100 calories a day, or about 
60 calories per kilo, of body weight. During Periods IV 
and V the patient was on a slightly lower calorific intake, 
but entirely adequate; namely, 960 calories per day, or 
about 50 calories per kilo, of body weight. 

The nitrogen of the food was estimated by the Kjeldahl- 
Gunning method and the fat by Soxhlet extraction. The 
urine was collected in twenty-four-hour periods, and por- 
tions passed during that period were preserved under 
toluene in an ice-chest. The urine was acid to litmus at 
all times. 

In the analysis of the urine the total nitrogen was de- 
termined by the Kjeldahl- Gunning method; armnonia by 
Folin's 120 method; urea by Benedict's 41a method; uric acid 
by Folin's colorimetric method; 123 creatin and creatinin by 
Folin's method; 121 and the hydrogen ion concentration 
according to Henderson's technique. 173 

In the study of the faeces the fat content was deter- 
mined by the Folin- Went worth method; 122 the iron was 
estimated by Neumann's method; 315 nitrogen by the Kjel- 
dahl- Gunning method, and urobilin by a slight modifica- 
tion of the method recommended by Wilbur and Addis. 473 

Period III (Table LV) was considered a desirable 
control on account of the high figures for uric acid obtained 
in the first and second periods. The analyses in this period 
were therefore limited to those determinations of special 
interest in this connection. 

Results of Metabolism Study. — In Table LV are 
presented the results of the study of nitrogen metabolism. 

Nitrogen Metabolism. — During Periods I and II, be- 
fore splenectomy, the sub j ect showed a slightly plus nitro- 



212 



THE SPLEEN AND ANAEMIA 



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METABOLISM STUDIES ON MAN 



213 



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214 THE SPLEEN AND ANAEMIA 

gen balance. After splenectomy, during Period IV, a 
great retention of nitrogen occurred, although the intake 
varied but little from the previous periods and the sub- 
ject was not gaining in weight. The logical explanation 
of this change would be either of the following : ( 1 ) Re- 
parative processes going on in the body, as indicated by 
the rapid regeneration of the hsemoglobin and red cells, or 
( 2 ) the removal of toxic influences, leading to an improve- 
ment in the general nutritive condition and thus to the 
normal nitrogen retention in a healthy child. The utili- 
zation of protein was good at all times. The average 
percentage of total nitrogen eliminated as urea was 85.5 
before splenectomy and 87.2 afterwards, figures within the 
normal range. The differences of the averages may pos- 
sibly be explained by the changes in one of the other nitro- 
gen constituents of the urine; namely, uric acid. 

Uric Acid. — The uric acid output was exceedingly 
high in Periods I and II. Period I was not purin-free. 
Period II, however, was practically free from purin intake, 
notwithstanding which the uric acid output continued on 
its high level. The urines were highly colored, and when 
allowed to stand gave a precipitate of uric-acid crystals. 
In view of this high elimination of uric acid a supple- 
mentary study was made (Period III), during which the 
subject was again placed on a purin-free dietary, consist- 
ing mainly of milk, eggs, shredded wheat, and custard. 
In this period the high output of uric acid, presumably 
almost entirely endogenous, still persisted. This average 
(Periods II and III) , 0.530 gm. of uric acid, is very close 
to the highest average of uric-acid output of an adult on 
a purin-free diet. Few figures for normal uric-acid out- 
put in children are to be found in the literature. Closson, 80 



METABOLISM STUDIES ON MAN 215 

in a child of about seven years of age, found an average 
output of 0.23 gm. on a purin-free diet. 

After splenectomy the average output of uric acid in 
Periods IV and V decreased 47 per cent, from the average 
of Periods II and III before splenectomy. It will be re- 
membered that the diets of all these periods were purin- 
free. The appearance of the urine in these later periods 
was markedly altered, the dark-red color being replaced 
by a pale yellow, with never a spontaneous precipitate of 
uric acid. 

Hydrogen Ion Concentration, — On the same general 
diet the hydrogen ion concentration of the urine remained 
constant before and after splenectomy. During Period I, 
on a mixed diet, an average of 5.87 falls within the normal 
average (5.94) of Henderson and Palmer. 174 On the 
purin-free diet yielding a more alkaline ash, the hydrogen 
concentration before operation is in agreement with that 
after the operation. It is of interest here to note that 
the hydrogen ion concentration is not appreciably altered 
by changes in uric-acid content of urine, although, as 
shown by Blather wick, 50 the ability of a urine to dissolve 
uric acid is a function of the hydrogen ion concentration. 

Ammonia Nitrogen. — The ammonia nitrogen in our 
experiments shows no variations from the normal. Its 
close agreement with hydrogen ion concentration may be 
noted ; thus a rise in the hydrogen ion concentration is asso- 
ciated with a fall in the ammonia output, and vice versa. 

Creatinin and Creatin. — The creatinin output showed 
a great constancy in Periods II and III, before splenec- 
tomy, on the purin-free diet. During Period I, on a mixed 
diet, the output is slightly above these periods. During 
Period IV, after the operation, the creatinin output fell 



216 THE SPLEEN AND ANAEMIA 

to its lowest point, a decrease of 25 per cent, from the 
average of the other purin-free periods. When the total 
creatinin (that is, preformed creatinin and creatin con- 
sidered as creatinin) output of each period is compared, 
one readily sees that the total creatinin, in all of the periods 
on creatin- free diet, shows a remarkable constancy. As 
will be seen from an inspection of the two tables, the de- 
crease of creatinin was accompanied by an increase of the 
creatin amounting to 91 per cent, of the average. Why, 
in Period IV, the partition of creatinin and creatin 
changed without an appreciable change of total creatinin 
is difficult to state. During the last two days of this 
period the patient suffered from a bronchitis with a rise 
in temperature, but that these are explanatory factors 
hardly seems plausible. 

As regards creatin output, with the exception of the 
first period, which was not that of a creatin-free diet, the 
output shows a fair degree of regularity. The increased 
output in Period IV has already been pointed out. 

There is a paucity of data on the creatinin and creatin 
output of children on controlled diets. The results ob- 
tained by Folin 125 on his children offer figures which may 
serve for comparison. 

The great constancy of our total creatinin (including 
preformed creatinin and creatin as creatinin) output leads 
us to believe that for the purpose of comparison in chil- 
dren this is the figure to be used rather than the relative 
or absolute amounts of creatin or creatinin. If we are 
correct in this view, the total creatinin output agrees very 
well with other published figures for children, and we 
therefore believe our creatin and creatinin figures to be 
within the range of normal variations. 



METABOLISM STUDIES ON MAN 



217 



Fats. — The total intake of fats and the separation of 
fats in the faeces are shown in Table LVL In this table 
Periods I and II represent the pre-splenectomy and 
Periods IV and V the post-splenectomy studies. Each 
period represents five days. 

TABLE LVI 

Fat Determinations in a Case of Congenital Hemolytic Jaundice Before 
and After Splenectomy 



Period 


Total 

intake, 

gm. 


Total 

output, 

gm. 


Per 

cent. 

of fat 

utilized 


Total 
output 
fatty 
acids 
including 
soaps, 
gm. 


Per 
cent, 
fatty 
acids 
in total 

fat 
output 


Total 

output 

neutral 

fats 


Per 

cent. 

neutral 

fats in 

total 

fat 

output 


Before Splenectomy : 


222 
223 

227 
269 


8.88 
7.57 

13.56 
13.55 


96.01 
96.62 

94.04 
94.98 


6.8 
5.1 

10.1 

9.8 


76.8 
67.0 

74.4 
72.3 


2.1 
2.5 

3.5 
3.7 


23.2 


II 


33.0 


After Splenectomy: 
IV 


25.6 


V 


27.7 







The metabolism of fats shows no abnormal variations. 
The fat utilization is good, and well within normal limits. 
As pointed out by Folin and Wentworth, 122 as total fat 
increases more of that fat is put out as fatty acids (includ- 
ing soaps). 

Iron. — Table LVI I presents the results of the exam- 

TABLE LVII 
Iron Elimination in Faeces in a Case of Congenital Hemolytic Jaundice 
Before and After Splenectomy 



Period 


Total intake 
period, mg. 
(calculated) 


Total output 

period, 

mg. 


Intake 
per day, 

mg. 


Output 

per day, 

mg. 


Before Splenectomy 
II 


37.69 


82.99 


3.77 


8.29 


After Splenectomy 
IV 
V 


45.61 


41.11 


4.56 


4.11 



218 THE SPLEEN AND ANAEMIA 

ination of the fasces for iron. As the iron in human urine 
seldom exceeds 0.001 mg., the urine is not included. 
Analyses for iron were made on duplicate samples of 
dried fasces representing periods of ten days, before and 
after splenectomy, respectively. 

Thus the first ten days correspond to Periods I and II 
and the second ten days to Periods IV and V. Periods II, 
IV, and V represent essentially the same diet. The figures 
for iron intake were calculated from published records 406 
of iron content of foods, hence no claim is made for the 
extreme accuracy of those figures. They merely serve to 
show that the iron content of the diet agreed veiy closely 
and would not account for the large difference of output. 
Those differences in output before and after splenectomy 
amounted to about 40 per cent, decrease. That the large 
output of iron in the period before splenectomy is due to 
the increased elimination of iron consequent on the ex- 
cessive destruction of red cells seems the most plausible 
explanation. The decreased elimination after splenec- 
tomy, with a close agreement of intake and output, shows 
a cutting off of this loss and presumably a return to normal 
elimination. 

Urobilin, — Our interest in the urobilin problem has 
been limited to the influence of the absence of the spleen 
on the elimination of this substance. In the urine quali- 
tative tests for urobilin gave negative results throughout 
the experiment. At one time, in a concentrated urine, a 
faintly positive reaction was obtained with Ehrlich's 
reagent. The large bulk of this constituent was in the 
fasces. Because of the small bulk of the child's fasces, 
and the necessity of utilizing considerable portions for 
other determinations, the use of the wet fasces for urobilin 



METABOLISM STUDIES ON MAN 219 

determination was impracticable. The faeces were there- 
fore dried in the usual way and placed immediately in well- 
stoppered bottles. At the end of the experiment the 
faeces of Periods I and II before splenectomy and IV 
and V after splenectomy were combined for urobilin esti- 
mation. In view of the previous work on this substance, 
it was to be expected that some of the urobilin would be 
destroyed, or that most of the urobilinogen would be con- 
verted into urobilin, but whether or not this took place we 
have no means of determining. The fact remains that 
considerable urobilinogen was still present at the time of 
analysis. Inasmuch, however, as both sets of fasces were 
treated alike, this was a more or less constant factor. Five 
grammes of faeces were extracted with 100 c.c. of acid 
alcohol and treated as described in method as outlined 
by Wilbur and Addis. 473 The dilution for total mass of 
faeces was then calculated. The dilution follows: 

Dilution required for extinction of urobilinogen and 
urobilin absorption bands: Periods I and II (combined), 
71,250; Periods IV and V (combined), 7954. 

These results are in accord with those described by 
Eppinger, 104 who found, in a variety of clinical conditions 
accompanied by rapid blood destruction, that the urobilin 
in the stools sank to normal after splenectomy. 

These general results may be summarized as follows: 

1. A slight positive nitrogen balance before splenec- 
tomy was followed by an increased retention eight days 
after operation. 

2. The output of uric acid showed a decrease of 47 per 
cent, after operation. 

3. In the period directly after operation a change in 
the partition of creatinin and creatin elimination occurred, 



220 THE SPLEEN AND ANEMIA 

the total creatinin, however, showing but slight change. 

4. Other urinary nitrogen constituents showed no vari- 
ations from the normal, and no change was found in the 
hydrogen ion concentration. 

5. The utilization of nitrogen was good at all times. 

6. Fat metabolism was normal. 

7. There was a large loss of iron through the fasces 
before splenectomy, followed by a decided decrease (40 
per cent.) after operation. 

8. The excretion of urobilinogen and urobilin in the 
faeces was markedly diminished after splenectomy; the 
amount after operation was about one-ninth of that ex- 
creted before splenectomy. 

In Pernicious Anaemia 

The second study 342 to be presented as a corollary to 
the above investigation has to do with certain phases of 
metabolism in an individual with pernicious anaemia char- 
acterized by increased haemolysis. The study was limited 
to the total nitrogen, the uric acid, the iron, and the uro- 
bilin and urobilinogen — substances in connection with which 
changes have been observed in the study of congenital 
hemolytic icterus. Three periods were studied: one be- 
fore the transfusion and splenectomy, one two weeks after 
splenectomy, and the third two weeks later. During each 
period the patient was on a carefully controlled Folin 
metabolic diet, and the period was not commenced until 
the patient had reached an approximate nitrogen balance. 
The nitrogen of the food and urine was determined by the 
Kjeldahl-Gunning method, the uric acid according to 
Folin's permanganate method, the iron by Neumann's 
method, and the urobilin and urobilinogen according to 



METABOLISM STUDIES ON MAN 



221 



the method of Wilbur and Addis. Only negligible amounts 
of urobilin or urobilinogen were at any time found in 
the urine. 

TABLE LVIII 
Blood Examinations in a Case of Pernicious Anaemia Before and After 

Splenectomy 





Haemo- 








Reticu- 




Date 


globin, 
per 
cent. 


Erythro- 
cytes 


Leuko- 
cytes* 


Nucleated 
erythrocytes 


lated 
erythro- 
cytes, 
per cent. 


Remarks 


3/28/15 


26 


1,150,000 


4,600 


Normoblasts + 
Megaloblasts + 




Coagulation time, 
4.5 min. 


4/ 8/15 


25 


1,620,000 


5,8Q0 


Megaloblasts + 






4/15/15 


20 


1,110,000 


2,000 





4 


Haemolysis in NaCl: 
partial 0.425, com- 
plete 0.325 


5/ 3/15 


20 


1,700,000 


6,500 





2 


Left hospital for a 
month 


6/ 5/15 


28 


1,300,000 


4,300 


Normoblasts -f- 


1 


Platelets less than 
100,000 


6/ 7/15 












Transfusion 900 c.c. 


6/ 8/15 


40 


1,810,000 


3^800 


o 






6/12/15 












Splenectomy 


6/15/15 


37 


1,420,000 


16, 600 






6/21/15 


40 


2,930,000 


12,000 


Normoblasts ++ 






6/24/15 












Severe haemorrhage 
from throat 












6/24/15 


27 










After the haemorr- 














hage 


6/28/15 


28 


1,640,000 


3,700 


Normoblasts + 






7/ 9/15 


31 


1,630,000 


6,300 









7/15/15 


35 


2,370,000 


6,000 


Normoblasts + 
Megaloblasts + 






7/22/15 


48 


2,030,000 


8,100 


Normoblasts + 






7/30/15 


55 


2,570,000 


7,400 


Normoblasts + 






8/ 6/15 


69 


2,300,000 


9,100 


Normoblasts + 


1 


Howell-Jolly bodies -j- 


8/16/15 


48 


3,200,000 


8,300 









8/24/15 


54 


3,700,000 


8,400 









8/29/15 


70 


3,580,000 


9,400 









8/30/15 










... 1 Discharged 


1/ 8/16 


83 


4,400,660 


10, 500 


Normoblast, 


Count by Dr. S. L. 










occasional Freeman 



* The differential counts of the leukocytes always showed a slight eosinophilia, but were 
otherwise normal. The erythrocytes showed the changes characteristic of severe anaemia; 
these became less marked as the anaemia disappeared. 

The history and findings in the case will be given 
briefly. The blood examinations are tabulated in Table 
LVIII and the metabolic results in Table LIX. 



222 



THE SPLEEN AND ANAEMIA 







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METABOLISM STUDIES ON MAN 223 

Clinical Notes. — The patient, a man, aged forty, had 
complained for two years of weakness, dizziness, dyspnoea, 
and oedema. These symptoms were steadily becoming 
worse. In other respects his history is unimportant. The 
physical examination revealed nothing noteworthy other 
than the signs of intense anaemia, associated with a lemon- 
yellow pallor. The liver-edge was just palpable. At 
operation the spleen was found to be about three times 
its normal size, weighing 340 gms. The pathologic ex- 
amination of the spleen showed chronic diffuse and fol- 
licular hyperplastic splenitis, with passive congestion and 
excessive pigmentation. The Wassermann was negative. 
On account of a constant eosinophilia, repeated careful 
examinations were made of the stools for ova or para- 
sites, but with negative results. The other laboratory 
reports are unimportant. The patient improved gradually 
after the splenectomy, and six months later was doing 
fairly arduous work, apparently in perfect health. 

The figures as given in Table LIX show that but 
little change in the elimination of uric acid and iron took 
place as a result of the splenectomy. The direction of 
the changes is, however, in each instance, in accord with 
the more pronounced changes in the study of congenital 
hemolytic jaundice, in which the hsemolytie factor is more 
marked. 

In view of the fact that the nitrogen balance is prac- 
tically identical in the first and third periods, it may be 
concluded that splenectomy in this case, as in other cases 
reported in the literature, has no permanent effect on the 
total nitrogen balance. The distinct positive balance dur- 
ing the second period is of interest, but probably of no 
significance in relation to splenic function. The uric- 



224 THE SPLEEN AND ANEMIA 

acid elimination before operation cannot be said to be 
other than a high normal figure, and the lower post-opera- 
tive figures are still within normal range; but when it is 
considered that the diet and regime in general were iden- 
tical before and after operation, the lowered output after 
operation is definite and significant. The same can be 
said of the figures for the iron elimination. 

In the combined urobilin and urobilinogen elimination 
a definite change is noted following the splenectomy. Two 
weeks after splenectomy the diminution in the urobilin 
output was negligible, the difference between 18,300 units 
per day and 16,000 being too slight to permit of signifi- 
cance being attached to it. Two months after splenec- 
tomy, however, at a time when the blood count showed a 
pronounced and most satisfactory improvement, the uro- 
bilin output had fallen to one-seventh of its former figure 
and had reached a low normal elimination. 

These observations may be summarized briefly as 
follows : 

1. A slight positive nitrogen balance before splenec- 
tomy was followed by an increased nitrogen retention 
fourteen days after operation and a return to the pre- 
operative balance after one month. 

2. The output of uric acid, although never exceeding 
normal limits, showed a decrease of 22 per cent, after 
operation. 

3. The output of iron through the faeces, although never 
above normal, showed a decrease of 40 per cent, after 
operation. 

4. The excretion of urobilinogen and urobilin in the 
fasces before splenectomy was about three times the nor- 
mal; two months after operation the output was about 
one-seventh of that before splenectomy. 



METABOLISM STUDIES ON MAN 225 

Discussion 

The literature concerning the relation of the spleen to 
metabolism may be considered under five heads: (1) 
Studies both before and after splenectomy for disease of 
the spleen in man; (2) studies in man after splenectomy; 
(3) studies of congenital hemolytic jaundice; (4 J" studies 
of anamiia; (5) studies of the effect of removal of the 
normal spleen. 

1. In only three instances other than those reported 
above have metabolic studies been made both before and 
after splenectomy for diseases of the spleen in man. Two 
of these are Umber's studies of Banti's disease, and the 
third Minot's study of pernicious ansemia. Umber studied 
two individuals splenectomized for Banti's disease, and 
Minot one in whom the spleen was removed as a last resort 
in pernicious angemia. One of Umber's subjects 444 was a 
boy of fifteen with ansemia and icterus, The post-operative 
period of study covered twelve days and began twenty- 
four days after the operation. The diet was purin-free, 
and a fully-controlled metabolic study was made. The 
results showed no pronounced variation in the distribution 
of the urinary constituents which could be attributed to 
the absence of the spleen. Umber makes a point, how- 
ever, of the fact that after removal of the spleen it was 
easier to obtain nitrogen equilibrium, and attributed the 
pre-operative pathologic destruction of protein to a toxic 
cause. His figures show also a somewhat greater output 
of purins before the operation than after. In another 
case of Banti's disease described in this report 444 the 
" toxic " disturbance of metabolism was not present and 
splenectomy was not done. In a later study 444 Umber 
describes a young man of twentv-one suffering from what 

15 



226 THE SPLEEN AND ANAEMIA 

he considers as the " toxic " type of Banti's disease. Sple- 
nectomy led to striking improvement. The metabolism 
study of this case was limited to a comparison of total 
nitrogen intake and output before and after splenectomy. 
The results confirm his former observation, namely, that a 
persistent negative balance before splenectomy changes to a 
positive balance after splenectomy. The post-splenectomy 
study was made three months after operation. Minot's 293 
patient was a colored woman, aged thirty-five, on whom 
the second period of metabolic studies were begun fifteen 
days after splenectomy and blood transfusion. The figures 
given for five twenty-four-hour periods before and six after 
splenectomy are not for consecutive days. The examina- 
tion included total nitrogen in urine and faeces, and urea 
and ammonia in the urine. The chief results were a change 
from a slight negative to a slight positive nitrogen balance 
and an increase in percentage of urea after splenectomy. 
The uncertainty of the food intake in the period before 
splenectomy, the low caloric intake, and the shortness of 
consecutive periods of observation make these balances 
of doubtful value. 

2. The following studies made after splenectomy have 
no fore-period for comparison. Lo Monaco 253 found in 
a splenectomized individual no important change in uric- 
acid elimination. 

Mendel and Gibson, 284 in the case of a man with 
enlarged spleen and secondary anaemia following malaria, 
studied the metabolism (total nitrogen, urea, uric acid, 
ammonia, phosphorus, chlorides, and sulphates) after 
splenectomy, but found no striking variation from the 
normal distribution of the urinary components. 

Likewise, Moraczewski, 297 who made some studies of 



METABOLISM STUDIES ON MAN 227 

both nitrogenous and mineral metabolism in a man of 
fifty-one, seven months after splenectomy for " spleen 
tumor" (malarial), found no important variations. His 
observations, however, were few in number and were made 
in the course of an attack of pneumonia which rendered 
matters of diet and control difficult. 

3. The only carefully-conducted and complete study of 
the metabolism in congenital haemolytic icterus is, so far 
as we are aware, that of McKelvy and Rosenbloom. 262 
The patient, a girl aged eleven, on a Folin diet, was studied 
for six days. The total nitrogen, fat, and mineral con- 
stituents of the food were determined and both urine and 
faeces studied as to nitrogenous and mineral constituents 
and the faeces as to fat. During a period of six days there 
was a loss of 4.06 gms. of nitrogen, which the authors sug- 
gest may be due to a toxogenic destruction of protein. 
The nitrogen partition of the urine was normal except in 
the case of the uric-acid nitrogen, which was increased. 
This increase, the writers state, might be due to the in- 
creased liberation of nucleoproteins through haemolysis 
of the erythrocytes. The study of mineral metabolism 
showed a loss of sulphur, iron, calcium, and magnesium, 
and a retention of phosphorus. The fat metabolism 
was normal. No metabolism studies were made after 
splenectomy. 

In a woman, aged thirty-nine, with " chronic family 
jaundice," Tileston and Griff en 435 studied, for three suc- 
cessive days and an added odd day, the output of am- 
monia, urea, creatin, and creatinin on a purin-free and 
creatin-free diet. They found the elimination of creatinin 
and urea to be essentially normal, ammonia somewhat high, 
and uric acid distinctly increased. However, it should be 



228 THE SPLEEN AND ANAEMIA 

noted that only one determination of uric acid was made. 

Haal, 161 in a case of family hemolytic jaundice, found 
an increased excretion of uric acid and of iron. 

4. As the changes in metabolism in various types of 
anaemia have recently been summarized by Minot, we will 
not present this literature in detail. The opposing views 
are represented by Rosenqvist and von Noorden. Rosen- 
qvist, 384 in pernicious anaemia and bothriocephalus anaemia, 
found variations in nitrogen elimination, with periods of 
alternate increased and decreased excretion. In bothrio- 
cephalus anaemia a well-marked loss of nitrogen, while the 
worm was in the body, was followed, after removal of 
the worm, by a nitrogen retention. Rosenqvist concluded 
that in both types of anaemia a pathologic decomposition 
of protein is present. Von Noorden 318 opposes this view, 
and as a result of his studies concludes that protein de- 
composition is not increased as the result of anaemia of 
the ordinary type. The variations in output, he believes, 
may be explained by the alimentary and renal disturbances 
which accompany anaemia. That an increased output of 
nitrogen may occur in anaemia due to parasites is admitted, 
as is also the possibility in non-parasitic anaemias of a 
temporary increase in the output of nitrogen as the result 
of a sudden destruction of large masses of red cells. 

As to uric-acid output, von Noorden refers to Rosen- 
qvist's high figures and to other observations and concludes 
that, as a rule, in anaemia the output is normal, but some- 
times rises, as in Rosenqvist's work, to twice the normal 
amount. 

It is noteworthy that in bothriocephalus anaemia Rosen- 
qvist found that after removal of the parasite the purin 
output increased temporarily and then returned to normal. 
This temporary increase he explains as due to the regen- 



METABOLISM STUDIES ON MAN 229 

eration and increased metabolic activity of the blood and 
somatic cells consequent on the removal of the toxic agent. 
As the cells recovered their normal equilibrium the output 
of the purins fell to normal level. 

Halpern, 163 studying one case of pernicious anaemia 
and one of splenic anaemia, found normal values for the 
various urinary constituents. His figures for purin output 
are in no way abnormal. 

Samuely, 391 in his studies of metabolism in dogs ren- 
dered anaemic by poisoning with pyrodin, found no essential 
changes in protein metabolism. 

5. The literature of splenectomy in man for conditions 
other than chronic anaemia, as, for example, gunshot 
wound, rupture, cyst, etc., shows that no metabolism 
studies have been made in such conditions. Conclusions 
concerning the effect on metabolism of removal of the 
normal spleens in the normal individual must therefore be 
based on observations on animals. 

Metabolic studies before and after splenectomy in 
animals, as we have shown elsewhere (see p. 181), indicate 
that the removal of the spleen does not influence protein 
metabolism. 

As to metabolism studies of substances other than pro- 
tein and its derivatives, the same paucity of data exists. 

The literature contains no records of the examination 
of the faeces for fat before and after splenectomy. Tiles- 
ton and Griffen, in one of their cases of chronic family 
jaundice, studied, without result, the fats of a single stool. 
McKelvy and Rosenbloom, in their case of congenital 
haemolytic jaundice, report normal fat metabolism. 

The literature of iron metabolism is, at best, unsatis- 
factory, and this is especially true of work on the relation 



230 THE SPLEEN AND ANEMIA 

of the spleen to iron metabolism. Most of the work is 
based on Schmidt's 395 conclusions, drawn from the results 
of the feeding of iron-poor food to normal mice, that the or- 
ganism possesses great power of conserving the iron and 
of reutilizing it through some form of intermediary metab- 
olism. In this connection Schmidt regards the liver as the 
depot for iron from the food, and the spleen as the depot 
for iron from tissue and erythrocyte catabolism. 

The experimental evidence concerning the relation of 
the spleen to iron metabolism, which we have described in 
detail elsewhere (see p. 112), is contradictory. Asher 
and his associates, Grossenbacher 16 and Zimmermann, 19 
claim that the dog after splenectomy eliminates an in- 
creased amount of iron. Our observations do not support 
these findings. In our early work we occasionally found 
a slight increase in the faeces one and two weeks after 
splenectomy, but in later studies an increase was never 
found except once in an anaemic animal. We are therefore 
inclined to view a disturbance of iron elimination in the 
dog as due to an associated anaemia rather than to the 
disturbance of some splenic function. 

No observations in man, other than our own ( see Table 
LX) on iron elimination both before and after splenec- 
tomy, are at hand. Bayer, 39 in the study of iron elimina- 
tion after splenectomy for (1) rupture of the spleen and 
(2) Banti's disease, compared his results with those ob- 
tained in normal individuals. He found an increased out- 
put soon after splenectomy in the case of spleen rupture, 
but later the elimination returned to normal; in the case 
of Banti's disease the elimination did not differ from the 
normal controls. A similar study has been made by 
Roth 385 with like results: iron elimination was studied 



METABOLISM STUDIES ON MAN 231 

in (1) a man, twenty-six years of age, whose spleen had 
been removed three years before because of splenomegaly 
associated with a type of hemolytic jaundice, presumably 
congenital, and (2) a man, thirty-seven years old, whose 
spleen had been extirpated one month before for rupture 
due to trauma. On both low and high iron diets the amount 
of iron absorbed by each, in relation to an estimated intake, 
was practically the same, but the output in the second 
individual was twice that of the first ; thus on the same iron 
intake the former eliminated 6.25 mgm. and the latter 12.18 
mgm. per day. These figures are in accord with the ex- 
treme for normal individuals, but one cannot avoid a query 
as to whether the time elapsed since splenectomy, three 
years as compared to one month, is not a factor in the 
widely different figures, or, again, whether the ear- 
lier anaemia in the first case may have been a factor. 
Indeed, the paucity of iron figures and the wide vari- 
ation in figures for normal individuals render their 
interpretation exceedingly difficult. This may be seen in 
Table LX, in which we have grouped all analyses, for 
normal and anaemic individuals, which we have been able 
to collect from the literature. McKelvy and Rosenbloom's 
studies of congenital hemolytic jaundice before splenec- 
tomy show, as do ours, that the elimination of iron in this 
disease is, on the basis of normal figures in the literature, 
increased. This increase they explain as due to the great 
destruction of red cells. 

From a review of the literature it is evident that in 
anaemia, with or without splenic disease, the majority of 
investigators have experienced difficulty in obtaining a 
nitrogen balance. Umber, 444 in his study of Banti's dis- 
ease; Minot, 293 in pernicious anaemia; McKelvy and Rosen- 



232 THE SPLEEN AND ANAEMIA 

bloom, 262 in congenital hemolytic icterus, and Rosen- 
qvist, 384 in pernicious anaemia and bothriocephalus anaemia, 
all report a pathologic destruction of protein. Umber 444 
goes so far as to urge this " toxic destruction " as a cri- 
terion for operation.* Von Noorden 318 alone opposes this 
theory of increased destruction of protein in anaemia. In 
the two cases we report, no difficulty was experienced in 
obtaining a positive nitrogen balance before operation: 
feeding was not forced, the patients merely satisfying their 
natural desires for food. Nevertheless, the increased re- 
tention immediately after the operation on the same nitro- 
gen intake would appear to support the theory that some 
toxogenic influence had been removed. To this influence, 
however, must be added as a cause of retention the higher 
level of reparative processes going on in the body, as, for 
example, in the bone-marrow and possibly other organs. 
It is, however, difficult to reconcile our slight positive 
balance with Umber's marked negative balance, before 
operation. 

As regards the elimination of uric acid in anaemia, with 
or without disease of the spleen, one finds the general 
view to be that the elimination is high. Rosenqvist (in 
1903), as a result of his studies of pernicious anaemia and 
bothriocephalus anaemia, reports large outputs of uric acid, 
sometimes twice the normal amount. He finds that after 
the removal of the worm in the latter condition there is 
first an increased elimination of purins and then a return 
to the normal. His explanation for this is an increased 
metabolic activity of the blood and somatic cells following 
the removal of the toxic agent. In our case, after removal 

*Luce, 256 Miiller/ 07 Lommel, 252 Grosser and Schaub/ 56 have 
failed to find an increased destruction of protein in Banti's disease. 



METABOLISM STUDIES ON MAN 233 

of the spleen, we found the reverse condition — an imme- 
diate drop to normal. That in our first case an increase 
took place between the time of operation and the Beginning 
of our first post-splenectomy period (eight days after 
operation) we cannot say. When, however, one inspects 
the results of blood examination after operation, it is ob- 
served that the increase in red cells and haemoglobin was 
steady and gradual, no greater during the first eight days 
after operation than during the subsequent ten days of 
our metabolism period, so that regenerative processes were 
at best gradual. 

Umber, in his studies, does not report uric-acid output, 
but groups his findings under total purins, of which he 
found, in Banti's disease, a somewhat greater output before 
operation than after. Haal, in family hsemolytic jaun- 
dice, found an increased excretion of uric acid. Von Noor- 
den gives as his opinion, based on a review of the literature, 
that in anaemia the output may be normal, but is sometimes 
increased. Lo Monaco, and Mendel and Gibson report no 
change in uric-acid excretion after splenectomy, but pre- 
sent no pre-splenectomy studies for comparison. 

In congenital hemolytic icterus McKelvy and Rosen- 
bloom report higher uric-acid output, buE present no studies 
after splenectomy. They give as an explanation for the 
increased output the greater formation of nucleoprotein 
resulting from the destruction of red cells. Their explana- 
tion seems to be inadequate, for it is difficult to imagine 
the destruction of red cells as being the sole source of 
this large output of purin. It may, to some extent, be a 
factor, but the toxic influence on the somatic cells gen- 
erally of bile products would appear to be a factor of 
greater importance. The sallow discoloration of the skin 



234 THE SPLEEN AND ANEMIA 

in the disease is indicative of the general dissemination of a 
substance absorbed directly or indirectly from the bile, and 
our knowledge of the toxic influence of bile constituents 
offers a possible explanation for a widespread state of 
cell degeneration and consequent repair which would 
account for increased output of products of nuclein 
metabolism. 

The only experimental studies which seem to have any 
bearing on this problem of protein metabolism are those 
of Jackson and Pearce, 338 who used hemolytic immune 
serum to produce liver necrosis and made detailed studies 
of associated changes in metabolism. The changes caused 
by hsemolytic serum — anaemia, jaundice, and cell degen- 
eration — represent as close an approach, aside from chro- 
nicity to conditions in congenital hsemolytic jaundice as 
can be brought about experimentally. It is of interest 
that under such experimental conditions an increased out- 
put of total nitrogen, rest nitrogen, pur ins, and phosphorus 
was observed. These changes were explained as due to 
cell autolysis consequent upon the necrosis of liver tissue ; 
when the necrosis was absent, little metabolic change was 
evident. It is impossible to make an exact parallel between 
an acute experimental lesion in animals and a chronic dis- 
ease in man, especially as the pathology of congenital 
hsemolytic jaundice offers no evidence of focal liver ne- 
crosis, but in view of the attempts of the several investiga- 
tors we have quoted to show a toxic destruction of tissue 
in hsemolytic anaemias, the experimental studies of Jack- 
son and Pearce are suggestive. 

The improvement in functional equilibrium after sple- 
nectomy, shown by the studies of protein metabolism, are 
emphasized by the studies of the exchange of iron. Our 



METABOLISM STUDIES ON MAN 235 

findings in congenital hemolytic jaundice and pernicious 
anaemia can be explained, when compared with the direct 
blood examination, only on the basis of an increased blood 
destruction before splenectomy and the removal of a hemo- 
lytic factor by the operation. And this view is tenable 
despite the fact that the figures for iron elimination before 
splenectomy are well within those given for normal indi- 
viduals (see Table LX). A study of figures for intake 
and output of iron and of elimination before and after 
operation leaves no doubt as to the influence on the iron 
exchange. Our results cannot be brought into relation with 
other investigations, as in no studies before ours has iron 
elimination been studied both before and after splenectomy. 
The results of our study of urobilin are in accord with 
the older views as to the source of this substance (that 
is, excessive blood destruction) , and also with the views of 
Eppinger concerning the decrease of urobilin after sple- 
nectomy in various diseases of the blood. The study of 
urobilin elimination has become a matter of considerable 
importance in prognosis after splenectomy. Its increased 
elimination is usually associated with other evidences of in- 
creased haemolysis, as high excretion of iron and uric acid 
and a discoloration of the skin, and its decrease after sple- 
nectomy is considered as indicative of the checking of 
haemolysis and as justifying a favorable prognosis. This is 
particularly true of congenital hemolytic jaundice, but 
observations concerning urobilin elimination in pernicious 
anaemia are somewhat contradictory. Thus Robertson 378 
emphasizes the fact that cases which had shown a high uro- 
bilin excretion before splenectomy and in which, after 
splenectomy, the urobilin output exhibited only a transient 
reduction, or none at all, did not show as much improve- 



THE SPLEEN AND ANEMIA 



TABLE LX 
Elimination op Iron in Healthy and Anaemic Individuals 









Iron in mgm. 




Observer 


Sex J 


Lge 






Remarks 








Intake 


Output 










per day- 


per day 




Lehmann, Muel- 


Male : 


26 


Fasting 


7.3 * 5 


Professional f asters; 10 


ler, Munk, 


Male I 


21 


Fasting 


7.7 


and 6 day periods re- 


Zuntz 244 










spectively 


Stockman and 


Male I J 


20 


6.2* 1 


6.32** 


Healthy individuals 


Greig 418 






5.6 


11.46* 2 






Male II ! 


55 


6.2 


8.33 






Female ' 


23 


3.5 


3.73 




Von Wendt « 


Male 1 




11.0 *i 


9.0* 4 


Nine periods of observa- 




2 




6.0 


11.0 


tion on two healthy in- 




3 




10.0 


14.0 


dividuals 




4 




8.0 


9.0 






5 




17.0 


42.0 






6 




7.0 


15.0 






7 




19.0 


24.0 






8 . 




28.0 


34.0 






9 




27.0 


32.0 




Sherman * n 


Male 




5.7 * 3 


5.5 ** 


Three healthy individuals 




Male 




6.5 


8.7 






Male 




7.1 


12.6 




McKelvy and 


Female 1 


Li 


8.8 * x 


32.51* 4 


Congenital hemolytic 


Rosenbloom 262 










jaundice — 5 day period 


Roth 385 


Male 5 


!6 


90.0 * 3 


6.25 * 4 


Hemolytic anaemia. Sple- 








150.0 


4.32 


nectomized 3 years pre- 
viously 




Male <: 


17 


90.0 


12.18 


Splenectomized one 








200.0 


33.07 


month previously for 
trauma of spleen 


Bayer 39 


Male ] 


L6 


240.0 *» 


9.38* 5 


Two weeks after splenec- 








140.0 


7.41 


tomy for traumatic 








130.0 


14.54 


spleen rupture. Three 








80.0 


5.92 


months later 








300.0 


26.73 






Male 1 


L6 


240.0 


8.40 


Control: Fracture of 








140.0 


7.29 


tibia 




Male 1 


L6 


130.0 


8.57 


Control : Osteomyelitis ; 








80.0 


3.57 


operation 14 days be- 


_ 






300.0 


23.49 


fore 




Female 3 


L9 


130.0 


13.86 


Morbus Banti; 2% years 
after splenectomy 




Female S 


!5 


130.0 


10.20 


Morbus Banti; Y^ year 
after splenectomy 




Female S 


57 


60.0 


21.46 


Morbus Basedow; before 
thymectomy 








60.0 


32.70 


Three weeks after 



METABOLISM STUDIES ON MAN 



237 



TABLE LX— Continued 
Elimination op Iron in Healthy and Anaemic Individuals 



Observer 


Sex 


Age 


Iron in 


mgm. 






Intake 
per day 


Output 
per day 




Goldschmidt, 
Pepper and 
Pearce 160 

Pepper and Aus- 
tin 342 


Male 
Male 

Male 


22 
5 

40 


60.0 

60.0 

130.0 

3.77* 3 

4.56 
16.5 * 3 

16.5 


12.83 

19.00 

3.59 

8.29* 5 

4.11 
17.0 * 5 

10.0 


Six weeks after 

Ten weeks after 

Morbus Banti; before 
splenectomy 

Congenital hacmolytic 
jaundice. Before sple- 
nectomy. 10 day period 

After splenectomy, 10 day 
period 

Pernicious ansemia. Be- 
fore splenectomy, 5 day 
period 

Two weeks after splenec- 
tomy, 4 day period 



** Iron intake determined by actual analysis. 

** Two periods on same individual; bulk of faeces in second period twice as great as in first. 

* s Iron intake estimated from tables. 

** Urine and faeces. 

* 6 Faeces only. 

ment in other respects as did those cases in which the 
urobilin output was permanently reduced. On the other 
hand, Lee, Vincent, and Robertson 241 state that in some 
cases of severe ansemia which showed marked symptomatic 
improvement for several months after splenectomy there 
was in the post-operative period a return to a continued 
high excretion of urobilin. 

More work is necessary before this problem can be con- 
sidered as settled, and it is to be hoped that metabolism 
studies before and after splenectomy will include not only 
the anaemias, but studies in essentially normal individuals, 
such as those with simple lesions of the spleen, unaccom- 
panied by anaemia. Studies of this latter type would 
eliminate present doubt as to the importance of the factor 
dependent on the absence of the function of the normal 



238 THE SPLEEN AND ANAEMIA 

spleen and thus offer the essential control, now lacking, 
for the correct interpretation of the metabolic disturbances ; 
that is, whether they are due to anaemia or the diseased 
spleen, or both. 

For the present, however, it seems justifiable to con- 
clude that splenectomy in the haemolytic anaemias is, as a 
rule, followed by a reduction in the elimination of uric 
acid, iron, and urobilin, changes indicative of decreased 
destruction of tissue and blood elements. 



Part II. 

CLINICAL OBSERVATIONS BY 
E. B. KRUMBHAAR 



CHAPTER XI 

CLASSIFICATION AND ANALYSIS OF TYPES OF SPLENO- 
MEGALY ACCOMPANIED BY ANAEMIA. 

Enlaegement of the spleen is a common accompani- 
ment of many clinical conditions, but in this chapter will 
be considered only such splenomegalies as are accompanied 
by anaemia; as, for example, Banti's disease, splenic 
anaemia, Gaucher's disease, hemolytic jaundice, and per- 
nicious anaemia, conditions in which the enlarged spleen 
seems to have an important relation to the anaemia. 

The connection between chronic enlargement of the 
spleen and marked anaemia without leukocytosis, as de- 
noted in the term " splenic anaemia," was first established 
fifty years ago by Gretzel, 154 in Griesinger's clinic, in 
Berlin. He describes the case of a child, ten months old, 
suffering from dysentery and severe anaemia, with con- 
siderable enlargement of the spleen and a lesser degree 
of enlargement of the liver and lymph-nodes. Examina- 
tion of the blood, by the crude methods then in vogue, 
showed that the proportion of white to red cells was not 
increased. Although later authorities have considered this 
to have been either a case of Hodgkin's or of von Jaksch's 
disease, it unquestionably served to differentiate a new 
clinical condition ; that is, it was made clear that the disease 
in question was not leukaemia. Five years later H. C. 
Wood 476 described a "splenic variety" of pseudoleu- 
kaemia, characterized by greatly enlarged spleen and severe 
anaemia, but without leucocytosis. Other case reports of 
like nature appeared from time to time, but it was not 

16 241 



\ 

L 



242 THE SPLEEN AND ANAEMIA 

until 1900 that Osier's 322 work familiarized the English- 
speaking public with the condition now generally known 
as splenic anaemia. The earlier descriptions, made at a 
time when the pathological anatomy of the spleen was little 
understood and when the methods of examining the con- 
dition of the blood were very inexact, constituted a dis- 
tinct advance, in that they differentiated a new type of 
disease previously confounded with leukaemia. The term 
"splenic anaemia " is now known, however, to include 
several distinct types, and its use should be restricted, if 
not, indeed, discarded entirely. The fact that in most 
cases the etiology or pathogenesis of this group of dis- 
eases is not yet clearly understood is no more an argument 
for continuing to group them under such loose terms as 
" splenic anaemia " or " splenomegaly with anaemia " than 
it would have been to continue to group typhoid fever 
with typhus fever until the discovery of the bacillus typho- 
sus. Though much still remains to be learned in regard 
to them, and though probably even their present eponymic 
and cumbersome names are only temporary, and will be 
found to include one or more entities, nevertheless it has 
already become more profitable to deal with them as inde- 
pendent affections. The inconvenience resulting from the 
present use of the term " splenic anaemia " is quickly dem- 
onstrated to anyone making a critical survey of the litera- 
ture. Statistical summaries, including valuable detailed 
information, are thus frequently rendered useless when, 
on analysis, they are found to include several independent 
types of splenic disease. Cases are occasionally reported 
under such headings as " simple hypertrophy of the 
spleen H or " idiopathic splenomegaly," in which not only 
has anaemia been absent, but histological examination of 



TYPES OF SPLENOMEGALY 243 

the spleen has failed to reveal any peculiar pathological 
change (Kidd, 212 Senator and Krause 404 ) . These reports, 
however, are so few in number and are based on such slight 
evidence that the conditions described are not as yet entitled 
to an independent consideration. In most cases names 
such as those quoted are used for the want of a more accu- 
rate designation, a practice that should be discouraged. 

Certain other diseases, in which the spleen is involved 
or said to be involved, will not be discussed in this chapter. 
These are ( 1 ) various hemolytic anaemias of specific origin 
( dibothriocephalus latus and uncinariasis), (2) lesions of 
the spleen associated with thrombosis of the portal vein or 
artery, and (3) some splenic types of cirrhosis of the liver. 
It must suffice thereby to indicate such relations. Also, all 
types of enlarged spleen in which certain features render 
differentiation easy (as leukaemia, pseudoleukemia, and 
changes secondary to obstruction or infection, as in heart- 
disease, typhoid, kala-azar, syphilis, etc.) will be omitted 
from consideration. This leaves the more definitely dif- 
ferentiated offsprings of " splenic anaemia " as Gaucher's 
disease (or large-celled splenomegaly), Banti's disease, v. 
Jaksch's pseudoleukemia infantum, the Hayem-Widal or 
acquired form of haemolytic jaundice with splenomegaly, 
and the Chauff ard-Minowski or congenital or familial form 
of the same. Some of the differential points of these dis- 
eases are indicated in Table LXI. 

Gaucher's Disease 

Gaucher's disease, or large-celled splenomegaly, was 

probably the first variety to be differentiated on account 

of its peculiar anatomical picture. Although in reality 

possessing little in common with the other forms of splenic 



244 



THE SPLEEN AND ANAEMIA 



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PLATE II 








Histology of Gaueher's disease. 



Alveolar arrangement of large vesicular cells with small 
concentric nuclei. 



TYPES OF SPLENOMEGALY 245 

anaemia, it is here considered in some detail, on account 
of the similarity of the clinical picture and from the fact 
that it is still included by many writers under that heading. 
Pathology. — First described by Gaucher, 139 in 1882, 
as a primitive epithelioma, it was later shown not to possess 
most of the characteristics of malignancy. Bovaird r ' 4 
called it a simple endothelial hyperplasia, and Brill and 
Mandlebaum 57 showed that the cells developed simultane- 
ously from the endothelium of the spleen, lymph-nodes, 
and bone-marrow. Diagnosis during life is not easy, but 
the characteristic large vesicular cells, with small eccentric 
nuclei, which block the sinuses of the spleen and lymph- 
nodes or are crowded about the liver lobules, render the 
recognition of the condition a simple matter to the pathol- 
ogist. A careful analysis by Brill and Mandlebaum has 
reduced the number of authentic reported cases to four- 
teen. Since that time cases have been reported by Herr- 
mann, 175 Knox, Wahl and Schmeisser, 219 and an unpub- 
lished case studied by Veeder, 451 in all of which the char- 
acteristic vesicular cells were found in the spleen and 
elsewhere. Mandlebaum and Downey, 273 however, reject 
Knox, Wahl, and Schmeisser's two cases, and restrict true 
Gaucher's disease to those cases in which the characteristic 
cells are arranged either in enormously enlarged sinuses 
surrounded by thick connective-tissue walls, or as solid 
masses surrounded by connective tissue. They consider 
that cases in which parenchymal cells (as in liver and 
adrenal) have undergone lipoid (?) change should not be 
considered as true Gaucher's disease. Knox, Wahl, and 
Schmeisser, on the other hand, hold that " any disease in 
which the spleen, together with any other organ, shows 
numerous large, pale granules or finely vacuolated cells 



246 THE SPLEEN AND ANAEMIA 

giving the characteristic microchemical reactions for lipoids 
and showing a tendency to be widely distributed, belongs to 
this (Gaucher) group." 

An acute form of Gaucher's disease, with fatal termina- 
tion after fifteen months, has been described by Niemann, 316 
under the title of " an unknown disease picture." The 
finding of characteristic large, endothelial-like vesicular 
cells at autopsy makes it probable that an acute form of 
this disease must also be recognized. 

Etiology. — Its etiology is still in doubt. Malignancy, 
having been discredited, various theories of endogenous 
toxins, splenic enzymes, or of infection have been offered, 
but none is supported by conclusive evidence. It is claimed 
that a similar histological picture can be produced in ani- 
mals by the forced feeding of cholesterin (McMeans, 263 
Luden 257 ). 

Symptomatology. — The excellent summary of Brill 
and Mandlebaum reveals the following clinical picture: 
The disease begins insidiously in infancy or childhood 
(usually before the thirteenth year) and pursues a very 
chronic course (average of twenty years). A history of 
similiar trouble in the family is frequently elicited. No 
great disturbance in the health of the individual occurs 
until the disease has persisted for some time, when distinct 
ansemia appears and, as in Banti's disease, a definite ten- 
dency to submucous or subcuticular hemorrhages. These, 
however, are never fatal, and death usually occurs from 
an intercurrent affection. The most prominent symptom 
is the progressive enlargement of the spleen, which may 
reach greater proportions than in any other disease, event- 
ually filling most of the abdomen. The abdominal dis- 
comfort produced by the enlarged spleen may be the first 



TYPES OF SPLENOMEGALY 247 

indication of the disease. As in Banti's disease, the blood 
changes are not very characteristic. The anaemia of chlo- 
rotic type is never very severe (average red blood-cell 
count of advanced cases being 3,700,000). A definite 
leukopenia is usually found, though the differential count 
remains unchanged. No enlargement of the superficial 
lymph-nodes can be found, and jaundice and ascites are 
rare. 

Liver enlargement, secondary to that of the spleen, 
may eventually reach considerable proportions. A brown- 
ish discoloration of the skin has been noticed with a 
" peculiar yellowish, wedge-shaped thickening of the con- 
junctivas, commonly seen on both sides of the corneae." In 
spite of the rather negative character of the symptoms, the 
disease has been recognized during life in at least four of 
the seventeen authentic cases, with a confirmation of the 
diagnosis by histological examination of material obtained 
by splenic puncture or after splenectomy. 

Prognosis. — According to Herrmann, Roth, and Bern- 
stein, 176 splenectomy has been tried in nine cases, with 
three deaths.* This probably represents too high a mor- 
tality, but, on the other hand, an ultimate cure can hardly 
be expected when the disease is known to exist independ- 
ently in the bone-marrow, lymph-nodes and elsewhere. 
Little is known concerning the power of the bone-marrow 
to react. The resistance of the red cells and number of 
skeined cells (as evidence of power of blood regeneration) 
have not been studied, but, in view of the absence of signs 
of increased haemolysis, one would not expect to find any 
noteworthy changes by such examinations. On the other 

* Veeder's unpublished case, with recovery after splenectomy, in- 
creases these figures to ten cases with three deaths. 



248 THE SPLEEN AND ANAEMIA 

hand, the red bone-marrow, usually present at autopsy, 
would point to efforts at regeneration. 

To sum up, this disease, despite the fact that it is fre- 
quently included among the " splenic anaemias/' has but 
little in common with them clinically beyond the chroni- 
cally enlarged spleen and anaemia. Pathological examina- 
tion should always allow the proper diagnosis to be made. 

Banti's Disease 
Symptomatology. — Banti's disease, or splenomegaly 
with hepatic cirrhosis, was first described by Guido Banti 30 
in 1894, and the clinical picture presented at that time still 
holds, although the etiology and pathogenesis of the disease 
remain in almost as great obscurity as at the time of its 
differentiation. Usually occurring in young, otherwise 
healthy adults and running a chronic course, its sympto- 
matology may be divided into three periods. In the first 
or pre-ascitic period, usually lasting several years, a grad- 
ually increasing weakness and pallor is noticed, with diges- 
tive disturbances and abdominal pain, which may first call 
attention to the enlarged, smooth, hard spleen. A ten- 
dency to hemorrhages with a moderate anaemia of chlo- 
rotic type is usually present, but may be postponed until 
the later stages. There is nothing specially characteristic 
of the anaemia, the increase of urobilin being the most 
significant sign of increased blood destruction. The resist- 
ance of the red cells is unchanged ; signs of a regenerating 
bone-marrow, as nucleated and reticulated red cells, are 
slight or absent. After splenectomy, however, an increased 
resistance of the cells may be noted, and may be marked.* 

* In a case I recently examined after splenectomy complete haemo- 
lysis did not occur in salt solution as low as 0.25 per cent. No nucleated 
red cells were found, but reticulated forms were more numerous than 
before splenectomy. 



TYPES OF SPLENOMEGALY 249 

A slight or moderate amount of leukopenia is char- 
acteristic. 

The second, or intermediate, stage lasts but a few 
months, and is characterized by scanty, high-colored urine 
containing an excess of urobilin, by attacks of dyspepsia 
and diarrhoea, and by slight increase in the size of the 
liver. 

The third stage is ushered in by the symptoms of cir- 
rhosis, a recurrent, painless ascites, occasionally slight 
jaundice, shrunken liver, and increasing anaemia and ema- 
ciation. After a few years an intercurrent infection or 
fatal hemorrhage is the terminal event. It is hardly neces- 
sary to say that such a picture is subject to variation, 
and that in some cases the three periods cannot be dis- 
tinguished. The first and second of these periods are 
usually considered as " splenic anaemia." 

Etiology and Pathogenesis. — In spite of the great 
amount of work done on Banti's disease in the past twenty 
years, not only is its etiology undetermined, but it is still 
an open question whether it is a disease due to a specific 
cause or is merely a fairly constant symptom-complex. 
Banti attempted to demonstrate microorganisms in the 
blood and viscera of this disease, but failed, as he did also 
in his various attempts to reproduce the disease in lower 
animals. He insisted, nevertheless, that the splenic en- 
largement was primary and due to an unknown infectious 
agent localized in the spleen. Recently Gibson 141 has 
reported the finding of a streptothrix in the spleens of 
certain cases resembling Banti's disease, and Yates, Bunt- 
ing, and Kristjanson 481 have found diphtheroid organisms 
in several such spleens. As these findings have not been 



250 THE SPLEEN AND ANAEMIA 

confirmed, however, and as the great majority of investi- 
gators have been unable to isolate a causative organism 
(Senator, 405 Sippy, 410 Zancan, 483 etc.), the demonstration 
of an actual infecting agent must be considered as still 
lacking. Suggestive evidence, however, was recently 
brought forward by Hollins, 183 who by repeated subcutane- 
ous injections of Bacillus coli was able to produce in the 
rabbit a distinct splenomegaly with moderately severe 
anaemia similar to that of Banti's disease. No hemolytic 
body or living microorganisms could, however, be demon- 
strated at autopsy. Banti's later view is that the in- 
fectious agent is brought to the artery either as a direct 
toxin or as a substance which is changed by an actual 
splenic metabolism into a splenotoxin. The earlier changes 
are therefore to be found in the neighborhood of the fol- 
licular arteries, and later in the pulp, splenic and portal 
veins, culminating eventually in the liver changes of the 
third stage. The symptoms, according to Banti, are due 
to general toxaemia, and the anaemia to a depression of 
bone-marrow activity rather than to excessive haemolysis. 
As the degenerative changes in the spleen are too far 
advanced to permit conclusions as to such a sequence of 
events, this theory has never been confirmed by experiment 
or observation. The intimate relationship between the 
spleen and liver renders intelligible a possible pathology 
of the third stage, especially as Mallory 271 and, later, 
Breccia 56 have shown that injury to the spleen is followed 
by focal necroses in the liver. Banti has objected to sug- 
gested etiological relationship of intestinal disturbances, 
despite the many cases in which digestive disturbances 
are known to precede or usher in the disease. The fact 



PLATE IV 



.^fL 






">■ ^ ' v 
















"V.*? 



Histology of spleen of early Banti's disease. 



TYPES OF SPLENOMEGALY 251 

that the spleen is involved earlier than the liver would 
point to a hematogenous rather than an enterogenous 
toxin, and the unquestioned improvement that usually fol- 
lows splenectomy indicates that the altered spleen is in some 
way an important pathogenetic factor. This is still fur- 
ther emphasized by Umber's 444 unique observation. A 
boy, fifteen years of age, was splenectomized for Banti's 
disease, and during the operation a small piece of the en- 
larged liver was excised for histological examination and 
a distinct peripheral infiltration of the lobules found. Later 
the liver returned to normal size, a strong indication of the 
splenogenous origin of the hepatitis, which, if undisturbed, 
should have progressed to the usual cirrhosis. 

Trauma to the spleen has been offered as a causative 
factor in some cases (Armstrong 12 ), while another group 
of authorities consider Banti's disease merely a syndrome, 
which a great variety of causes are capable of producing 
(Albu, 5 Isaac, 193 Luce, 256 Neuberg, 314 Seiler 402 ). There 
is no question that various conditions, as an atypical cir- 
rhosis of the liver with early prominence of splenic signs, 
syphilis, or primary endophlebitis or thrombosis of the 
splenic or portal vein can produce a picture which cannot 
be distinguished from that of Banti's disease (Edens, 101 
Goldman 148 ) . As endophlebitis or thrombosis is a fre- 
quent accompaniment of true Banti's disease, it is but 
natural that the symptomatology of the two conditions 
should be confounded. Banti himself called attention to 
the frequency of these changes in his original descriptions, 
but considered the splenic changes primary. Other authors 
consider that when the endophlebitis or thrombosis is pri- 
mary certain characteristic symptoms will often point 
toward a proper differential diagnosis. Warthin 462 in- 



252 THE SPLEEN AND ANEMIA 

sists that an infectious thrombophlebitis of the portal or 
splenic vein is the essential feature of the symptom-com- 
plex, whereas the upholders of the separate-entity theory 
claim that such changes are secondary to the changes in the 
spleen or may be absent altogether (Ziegler 486 ). In cer- 
tain cases of syphilis of the liver, also, the splenomegaly, 
anaemia, and history of hsematemesis may be so prominent 
that the picture of Banti's disease is very closely simulated 
(Osier 323 ). 

When a consideration of the above features allows a 
differentiation to be attempted it would seem advisable 
to consider such cases as pseudo-Banti's disease, and to 
restrict the use of the term true Banti's disease for those 
cases in which no such etiological factor is apparent. 

The nature of the splenic enlargement has also given 
rise to several hypotheses. The view that it is spodogenous 
can be ruled out, on account of the absence of histological 
evidence to support it, and Barr's 36 theoiy of splenic con- 
gestion due to splanchnic vasomotor paresis needs merely 
to be mentioned. The prevailing opinion is that the en- 
largement is due to a chronic inflammatory process, which 
in turn results in an increased functional activity (in- 
creased haemolysis), with a resultant anasmia. This view 
is in accord with Botazzi's hsemocatatonistic and Banti's 
hemolytic theories. Haemolysis is considered by Harris 
and Herzog to be due to an erythrolytic enzyme elab- 
orated by the hyperplastic endothelial cells, and by Lint- 
varew to an increase in the erythrophagic action of the 
spleen-cells, the resultant fibrosis being due to the chronic 
irritation of the products of red-cell destruction. The 
absence in the circulating blood of signs of bone-marrow 



PLATE V 






*M t 







£" .^< V "?:::- ■- i ^" 



- ■■ ■ - 

gag 






Ul 



&m%M 



Histolos - n of late Banti's disease. 



PLATE VI 




o 

■ *<* 







Histology of spleen of congenital haemolytic icterus. 



TYPES OF SPLENOMEGALY 253 

activity points, however, to a diminished activity in blood 
formation, but against this is the increased urobilin elimina- 
tion as evidence of increased blood destruction. The 
probable existence of a splenic hormone to the bone-marrow 
and its disappearance in splenic disease can be invoked to 
explain the greater anaemia when the splenic tissue has been 
largely replaced by fibrosis; but, on the other hand, the 
improvement in the blood picture that follows splenectomy 
suggests the removal of a pernicious hemolytic activity on 
the part of the spleen. 

Pathology. — In the pathological histology of the dis- 
ease there is nothing specially distinctive. The enlarged 
spleen, as a rule, shows an increased amount of fibrous 
tissue in the capsule and reticulum, usually characterized 
as " fibroadenie " (that is, increased fibrous tissue, but re- 
taining an adenoid appearance), and involving both pulp 
and follicles. The Malpighian follicles, especially in the 
later stages, are small and scarce ; in the earlier stages they 
may be hyperplastic and the " fibroadenie " be absent. 
Macrophages, increased amount of pigment, and other 
evidences of increased blood destruction are usually found. 
The changes in the liver are those of an ordinary periportal 
cirrhosis. 

In summarizing, one might say that, although the eti- 
ology of true Banti's disease is unknown and may well be 
from several sources, evidence points to the close causative 
relationship of the spleen. One would not expect the re- 
moval of a largely fibrotic organ to be attended with 
marked somatic changes, and it is precisely in the earlier 
stages of the disease in which splenectomy has proved 
most beneficial. 



254 THE SPLEEN AND ANEMIA 

Von Jaksch's Disease 

The anemia infantum pseudoleukemia of von 
Jaksch 198a is in all probability not an independent condi- 
tion, but represents an atypical response of the infantile 
hemopoietic system to one or other of the primary dis- 
eases of the blood (leukemia, pernicious anemia, the 
secondary anemia of rickets, syphilis, Banti's disease, or 
the formerly unrecognized types of hemolytic jaundice). 
As a rule, a high-grade anemia, with blood picture some- 
what resembling pernicious anemia, appears in infants 
of one or two years. Leucocytosis, especially of the small 
lymphocytes, is a frequent response to any form of anemia 
in infancy and childhood. The smooth, hard spleen is con- 
spicuously large, while the liver, in contrast to the liver of 
leukemia in childhood, is very slightly enlarged. Aschen- 
heim and Benjamin 13a have found rickets present in all 
of a series of such cases examined by them, and suggest 
the name " Rachitische Megalosplenie " for this condition. 
Von Jaksch also associated rickets with this disease. 
Giffin 144 and others, on the other hand, consider the true 
v. Jaksch's disease to be nothing more than the infantile 
form of splenic anemia. (Banti's disease.) That von 
Jaksch's disease is being less and less regarded as a sepa- 
rate disease is shown by the gradual disappearance of the 
name from the text-books. 

Hemolytic Jaundice 

The acquired, Hayem-Widal, and congenital or famil- 
ial, ChaufFard-Minkowski types of hemolytic jaundice 
with splenomegaly are frequently grouped by English and 
American authors under such titles as " hemolytic jaun- 
dice" (Thayer 431 ), and "chronic family jaundice" 



TYPES OF SPLENOMEGALY 255 

(Tileston 435 ). As the two forms possess several rather 
important and characteristic differences, it is deemed ad- 
visable to follow the continental custom and consider them 
as independent conditions. Search for their true etiology 
and pathogenesis (as yet unknown) is more apt to be 
stimulated under such an arrangement than if they are 
grouped together. Furthermore, Widal, Abrami, and 
Brule 470 experimenting with toluylenediamine, have offered 
evidence to indicate, in their opinion, that the two types are 
of different origin. 

Symptomatology. — The points of differentiation we 
will present after outlining the historical development of 
our general knowledge of hasmolytic jaundice. Although 
Murchison, 308 Wilson, 474 and others had previously de- 
scribed cases of chronic j aundice occurring in several mem- 
bers of a family (in Murchison's case splenomegaly is not 
mentioned), it was the more complete description of 
Hayem, 171 in 1898, that first established the condition as a 
clinical entity. The clinical picture of the five cases ana- 
lyzed by him was as follows : All five exhibited a chronic 
jaundice, with the presence of bile-pigment in the blood- 
serum, but not in the urine (i.e., acholuric icterus). The 
other signs of obstructive jaundice, such as itching, brady- 
cardia, and clay-colored stools, were also lacking. A dis- 
tinct anaemia, the red-cell count varying from 1,000,000 to 
3,000,000, was present in all. Very large, hard spleens 
were found in each case, and slight enlargement of the liver 
was also noted. Exacerbations were frequent, and during 
these the j aundice deepened and bile appeared in the urine. 
The importance of these exacerbations was emphasized by 
Widal, who termed them " crises of deglobulization," and 
considered them highly characteristic of the acquired form. 



256 t THE SPLEEN AND ANAEMIA 

In severe cases the blood count fell below 1,C00,000 and 
haemoglobin appeared in the urine. In all five of Hay em's 
cases the family history was negative, and in three the jaun- 
dice was stated to have appeared first in adult life. 

Two years later Minkowski 291 described a similar dis- 
ease occurring during three generations in eight members 
of one family. This, the congenital form, it is now 
known, is commoner than the acquired form. In addition 
to the symptoms presented by Hayem's cases, an increased 
amount of urobilin was noted in the urine. Autopsy re- 
vealed no cirrhosis of the liver or obstruction of the bile- 
passages. The spleen showed a diffuse hyperplasia and 
hyperemia. Pigment deposits were numerous in the kid- 
neys and in the centres of the liver lobules. 

The next important contribution to the clinical pic- 
ture of these diseases was made by ChaufFard, 72 who showed 
in the congenital type that the resistance of the red blood- 
cells to hypotonic salt solution was much diminished. 

Increased number of microcytes and of reticulated red 
cells by methods of vital staining were found by Chauf- 
fard 72 in the congenital or familial type, and their presence 
later confirmed also in the acquired type. 

Another diagnostic method, the auto-agglutination 
test, is advocated by Widal, Abrami, and Brule. 471 They 
have found it always positive in the acquired form and 
always negative in the congenital or familial type. How- 
ever, in Micheli's 289 carefully studied case of the acquired 
type this test was also negative. Isohsemolysins have occa- 
sionally been found in both types (Micheli, 289 Hopkins 184 ) , 
but are not supposed to possess any pathological signifi- 
cance. Although both types of hsemoly tic j aundice usually 



TYPES OF SPLENOMEGALY 257 

run a chronic course, Gaisbock 13G has shown that an acute 
malignant form may occur that is fatal in a few months. 

Therefore the cardinal symptoms of the two types of 
hemolytic jaundice with splenomegaly are found to be a 
chronic enlargement of the spleen, existing with an acho- 
luric, non-obstructive jaundice, and anaemia, frequently 
paroxysmal in character and varying in intensity. In- 
creased blood destruction is indicated by increased urobilin 
in the urine, and various characteristic changes are found 
in the blood. The red cells show diminished resistance to 
hypotonic salt solution, increased number of reticulated 
cells with vital staining, and in the acquired form the 
phenomenon of auto-agglutination of the red corpuscles. 
The blood-serum rarely contains auto- or isohaemolysins. 

We have purposely postponed until now a considera- 
tion of the differentiation of the acquired and familial 
types and their relation to other conditions, such as those 
suggested by Gilbert 146 and Banti. 31 The fact that in the 
acquired group the disease is definitely acquired in adult 
life, whereas in the other there is a family history of the 
same trouble, is not in itself sufficient to warrant the dis- 
tinction of independent disease pictures. There are, how- 
ever, other features which tend to differentiate the two 
types. In the congenital form the subjects, as Chauffard 
puts it, "are more icteric than sick." Frequently they 
come for treatment for other conditions and consider the 
chronic jaundice as a family idiosyncrasy not interfering 
with perfect health. The acquired form, on the other hand, 
is usually ushered in with a definite attack of illness; the 
anaemia becomes much more grave, sometimes as low as 
1,000.000, and the patient is distinctly more anaemic than 
jaundiced. In Decastello's 91 case, which was greatly im- 
17 



258 THE SPLEEN AND ANAEMIA 

proved by splenectomy, the red-cell count had previously 
fallen to 800,000. 

An analysis of 159 cases of hsemoly tic jaundice in which 
blood counts are available shows that 55 belong to the 
acquired type and 104 to the congenital or familial type. 
Of the latter, only 23 failed to give a positive family his- 
tory; but of the 81 remaining cases the disease in 36 de- 
veloped after birth. The term " familial " would there- 
fore seem preferable to that of " congenital," unless a third 
variety is to be considered. The average red-cell count of 
the 55 acquired cases is 2,032,000, the counts ranging from 
510,000 to 4,500,000. Counts below 1,000,000 are recorded 
in ten cases ; below 2,000,000 in 27 cases, and over 4,000,- 
000 in only four cases. The average count of the 103, 
congenital and familial, is 3,340,000, the counts ranging 
from 1,800,000 to 5,700,000.* No counts are recorded 
below 1,000,000 ; eight below 2,000,000, and 25 above 4,000,- 
000. If this group is subdivided, the average of the 
familial cases is 3,281,000; of the congenital, 3,543,000. 
These figures show that there is a more marked anaemia 
in the cases of the acquired type than in either the familial 
or congenital types. 

Widal and his pupils claim that the auto-agglutination 
test is only positive in the acquired form, and consider this 
as important evidence that the two diseases have funda- 
mentally different origins. Attention has already been 
called to the differential importance of Widal's " crises of 
deglobulization," but it must be admitted that marked 

*One familial case reported by v. Krannhals showed 1,000,000 
red cells in a single count, but, as the haemoglobin was between 55 and 
65 per cent., the accuracy of the count is questionable. 



TYPES OF SPLENOMEGALY 259 

fluctuations in the degree of blood destruction are present 
also in the familial type. 

Numerous reports are at hand of a condition apparently 
identical with the acquired form, but following attacks of 
malaria, syphilis, and other infections. In such cases the 
signs of excessive blood destruction usually disappear when 
the underlying cause is successfully treated. The familial 
form, on the other hand, appears more as an inherited 
dystrophy of the hemopoietic system, rendering the red 
blood-cells more easily destructible. On this basis Chauf- 
fard at first strongly advised against splenectomy in this 
type, but subsequently cases have shown such improve- 
ment after this treatment that it would seem as if the 
removal of this site of blood destruction was advisable, 
whether or not it is the primary seat of the trouble. It 
must be noted, however, that after Kahn's 206 and Roth's 386 
successful splenectomies in the familial type the resistance 
of the red cells failed to return to normal. The congenital 
type with negative family history, grouped with the familial 
type by most authors, offers no definite ground for differ- 
entiation from the acquired form. The mere fact that the 
disease has already made its appearance at birth is of it- 
self not of fundamental importance if there is no history 
of similar trouble in the family. If the familial form 
(which, as a matter of fact, is usually, though not always, 
congenital) were placed in contrast to the acquired form, 
the time of onset, as indicated by the term congenital, 
might well be disregarded. The possibility of an early 
acquisition of the disease is shown in the case reported by 
Benech and Sabrazes. 41 With a negative family history, 
a suckling is supposed to have acquired the disease from 
her wet-nurse, who, together with her two children, had 



260 THE SPLEEN AND ANEMIA 

a chronic hemolytic jaundice. Certain authors consider 
the acquired and congenital types as identical. Hynek, 191 
for instance, bases his opinion on two cases observed by 
him : in one a mother acquired the disease after childbirth, 
whereas in her child it appeared congenitally. Plehn 355 
reports a case appearing congenitally in father and daugh- 
ter, but not until the twenty-sixth year in the case of a 
son. Benjamin and Sluka 42 observed three cases in one 
family, two appearing congenitally and one in adult life. 
Many of these cases could undoubtedly be harmonized if 
the time of onset were disregarded. 

In favor of the identity of the two types (acquired 
and congenital) it must be admitted that a series of cases 
could be selected in which many grades between the two 
types would be represented. It is obvious that the familial 
type must at one time or another have originally been 
acquired. In such an event the difference in severity be- 
tween the acquired and familial still holds. Thus both in 
Roth's 386 and Bychowski's 64 cases the disease in the parent 
who acquired it was severe, while in the children who in- 
herited it it was of the usual mild type. Such facts, how- 
ever, would not indicate a fundamental difference in the 
nature of the two diseases. 

In the small number of cases already accumulated vari- 
ous atypicalities have been reported. Thus, Lommel's 252 
and Claus and Kalberlah's 79 cases of the familial type and 
Mosse's 304 and Tixier's 436 cases of the acquired type failed 
to show any change in resistance of the red cells (either 
washed or the whole blood), though other evidences of 
increased blood destruction were present. In a few cases 
an acholuric jaundice with splenomegaly has existed to- 
gether with polychythsemia instead of anaemia. Chauffard 



TYPES OF SPLENOMEGALY 20 1 

and Vincent 7G and Roth 387 have recently described a 
form in which hemolysins are present in the blood, and such 
cases appear to occupy a position midway between hemo- 
lytic jaundice and paroxysmal hemoglobinuria " a fri- 
gore." Gilbert 14G and his pupils have published numerous 
reports since 1900 on similar conditions under the name 
of " cholemie familiale." They have at least served to 
call attention to the fact that variations may be found in 
the amount of enlargement of the spleen and liver. It is 
questionable, however, if it is necessary, as they have fre- 
quently done, to consider each atypical form as a separate 
condition to be dignified with a separate name. As many 
of their cases were described before the various hemato- 
logical methods above described had come into vogue, and 
are frequently reported in resume, it is difficult to deter- 
mine conclusively whether or not they should be considered 
as belonging to the types under discussion. Their theory 
of hepatic origin, through an infectious angiocholitis, they 
later abandoned in favor of Chauffard's idea that the pri- 
mary change was in the blood. 

Another occasional variation is in the presence of all 
symptoms of increased blood destruction but an absence 
of icterus. This ChaufFard describes in a family in which 
the mother is a typical hemofytic icteric, while the eighteen- 
year-old son presents all the signs of the disease except 
jaundice. 

When the anemia is grave the blood may present a 
picture indistinguishable from pernicious anemia (v. 
Stejskal 415 ) . ChaufFard considers that there is an icteric 
form of pernicious anemia which, when accompanied by 
diminished resistance and reticulated red cells, represents 
the least compensated form of hemolytic icterus. Widal 



262 THE SPLEEN AND ANAEMIA 

and Weissenbach 472 have also reported a case of this type. 
In the usual Biermer type of pernicious ansemia, icterus, 
it will be recalled, is absent and the resistance of the red 
cells increased. 

Banti 32 has recently proposed the name " hemolytic 
splenomegaly " for a type of the disease which on analysis 
is indistinguishable from the acquired form of hsemolytic 
jaundice. Both the cases described by him exhibit a 
chronic anaemia, with long-standing splenomegaly, subic- 
terus, diminished resistance of the red cells, increased num- 
ber of reticulated cells, and urobilinuria. In a later study 33 
of seven cases of this condition he further subdivides 
" hsemolytic splenomegaly " into regenerative and degen- 
erative groups, the difference depending chiefly on periods 
of relapse and remission in the former type, with greater 
evidences of regeneration in the blood picture. The bene- 
ficial effects of splenectomy — abolishing the ansemia and 
changing the resistance to normal in one case and even 
changing an aplastic into a reacting bone-marrow — lead 
him to ascribe a primary role in this disease to the spleen. 
It must be remembered, of course, that removal of the 
normal spleen indirectly causes an increase in resistance 
of the red cells. Banti claims never to have seen Widal's 
crises of deglobulization in these patients, and emphasizes 
the presence of a relative lymphocytosis, but this would 
hardly indicate a different disease. As to the choice of 
name, Banti's name is open to the same objection as the 
older one; namely, that splenomegaly may be absent in 
some cases (Le Gendre, 243 Pick, 353 Gilbert and Lereboul- 
let, 146a Benjamin and Sluka's third case, and Marchiafava 
and Nazzari, 276 ) just as jaundice is in others. A name 
indicating increased blood destruction, such as " hsemo- 



TYPES OF SPLENOMEGALY 263 

lytic Hypersplenism," without including individual fea- 
tures, would be less open to objection; but in the mean- 
time, until hypersplenism can be demonstrated, the name 
sanctioned by usage is preferable. 

Pathogenesis. — As I have already indicated in the 
discussion of the differentiation of the two types, a hepatic 
or luetic etiology has been largely discarded. Such etiology 
is, however, still occasional^ reported (Bernard, de Beru- 
mann, Gelle), as is also that of malaria (Socquepee) and 
ankylostomiasis (Darre, Parisot, and Fairise). The two 
prominent views, however, are ( 1 ) that the primary lesion 
is in the blood — a dystrophy of the red cells; or (2) either 
primarily or indirectly in the spleen — an exaggerated 
hemolytic activity. Widal and his school, the extreme 
supporters of the former view, consider that the congeni- 
tally weak red blood-cells are destroyed in the circulation 
and their remains taken up by the spleen, causing a spo- 
dogenous tumor, and by the liver, kidney, and bone-mar- 
row, as shown by the excessive pigment deposits found in 
these organs at autopsy. This view was supported by 
Vaquez, 450 von Stejakal, Benjamin and Sluka, Aschen- 
heim, 13 and Weber and Dorner. 463 The chief objection to 
it is that it completely ignores the great improvement fol- 
lowing splenectomy. A primary increased hsemolytic 
activity of the spleen as the source of the malady was first 
proposed by Minkowski and supported by von Krannhals 
and ChaufFard. Its latest adherent, Banti, as I have pre- 
viously stated, considers that the pathological spleen not 
only is spodogenous, but actively destroys increased num- 
bers of cells and prepares others for destruction. Though 
based on incorrect and inadequate experimental evidence, 
this attractive combination of the splenogenous and hsemo- 



264 THE SPLEEN AND ANAEMIA 

catatonistic theories at present seems most plausible. 
Although it is not possible to demonstrate haemolysis in the 
normal spleen, we cannot exclude the possibility that it 
exists and that it is active in some diseased conditions of 
the organ. Extracts from the spleens of Antonelli's, 9 
Kahn's, 206 and Robertson's 379 cases, however, failed to 
show any hsemolytic activity in vitro. 

Whatever the source of the increased blood destruction, 
there results an increased amount of free haemoglobin to 
be gotten rid of. Most authorities believe that this is 
changed by the liver into bile in excessive amounts, and 
that the viscid and highly pigmented bile clogs the bile- 
capillaries, is reabsorbed into the blood, and thus causes a 
" pleiochromic icterus." Recent investigations by Whip- 
ple, 466 however, show that bilirubin can be formed by 
the action of the endothelium of blood-vessels entirely iso- 
lated from the hepatic circulation. If this be true, a 
hematogenous icterus in the narrower sense can be ac- 
cepted. That the jaundice is not due to gross obstruction 
is proved by the facts that such obstruction has never been 
found, that the stools are of normal color, and that the 
urine does not contain bilirubin. 

It is interesting to note that in Banti's aplastic or 
ansemopoietic case splenectomy started the formative 
powers of the bone-marrow, as shown by the appearance 
of normoblasts in the circulating blood. This would indi- 
cate that with the spleen was removed a toxin that had 
inhibited blood formation, and from this it could be argued 
that the decreased resistance of the red cells of hsemolytic 
jaundice is due, not to a hsemocatatonistic action of the 
spleen, but to an indirect injury to the bone-marrow. 

Pathological study of the comparatively few cases of 



PLATE \ II 




Spleen of pernicious anaemia. Detail drawing shows phagocytosis of red cells and blood pigment. 



TYPES OF SPLENOMEGALY 265 

hemolytic jaundice that have come to autopsy or sple- 
nectomy has yielded little in the way of establishing a con- 
stant and characteristic pathological picture. I have col- 
lected descriptions of seven spleens obtained at autopsy 
and of eight obtained after splenectomy. An analysis of 
these appears in Table LXII. 

It will be seen that the chief characteristic of both types 
of the disease is the marked congestion of the splenic pulp 
and splenic sinuses, but this is, of course, found in many 
other conditions. The Malpighian follicles, the capsule, 
and trabecular are frequently left unchanged; and, while 
pigment deposits and macrophages have usually been 
found to be increased, in the case reported from this labora- 
tory this was not found to be true. In all cases in which 
the bone-marrow was examined at autopsy it was found 
to be red. 

Pernicious Anemia 

This disease is mentioned briefly here, not as an ex- 
ample of splenomegaly, but because the recent tendency 
to treat it by splenectomy brings it into relation with the 
theory of Hypersplenism.* This latter theory has been put 
forth prominently in recent years by Eppinger 104 and 
King, 213 who consider that the amount of haemolysis in a 
given case is in definite relation to the amount of unsatu- 
rated fatty acids and the amount of urobilin in the faeces. 
They found both these increased not only in Haemolytic 
jaundice, but also in pernicious anaemia, hypertrophic cir- 
rhosis, and catarrhal jaundice. For example, the unsatu- 
rated fatty acids, as may be seen in Table LXIII, rise 
from a normal (iodine number) of 80 or 90 to 188 to 273 

# For summary of recent literature on this subject see Vogel. 456 



THE SPLEEN AND ANAEMIA 



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TYPES OF SPLENOMEGALY 



267 



in pernicious anaemia. As they had found experimentally 
that removal of the spleen in the dog caused a great drop 
in the iodine number and was associated with an increased 
resistance of the red cells and lessened tendency to haemo- 
lysis, they favor splenectomy in this type of anaemia. 
Eppinger's theory of the pathogenesis of pernicious anae- 
mia is interesting, but not convincing. On histological 

TABLE LXIII 

Analysis op Blood Fat in An.emia and Other Conditions * (Modified 
from Table of Eppinger 1CA and King 2U ) 



Total 
fat 

gms. 


Choles- 
terin 
gms. 


Choles- 
terin 
ester 

gm. 


Iodin 
number 


5.3S 


0.76 


0.52 


90 


5.90 


0.86 


0.57 


79 


7.34 


0.56 


0.72 


188 


8.40 


0.32 


0.01 


213 


9.37 


0.14 


0.05 


273 


5.43 


0.49 


0.41 


326 


6.33 


0.S5 


0.31 


258 


9.35 


0.91 


0.31 


125 


3.94 


0.30 


0.13 


309 


7.36 


0.56 


0.12 


82 


5.70 


0.50 


0.23 


187 


5.40 


0.39 


0.44 


123 


5.60 


0.4S 


0.67 


122 


10.63 


1.07 


0.27 


88 


7.92 


0.61 


0.49 


139 


6.39 


0.71 


0.52 


36 


6.97 


0.3S 


0.44 


101 


8.24 


0.56 


0.3S 


22 


15.S9 


1.26 


0.07 


69 


5.93 


1.09 


o.os 


273 


8.50 


0.S6 


0.63 


224 



Normal 1 

Normal 2 

Pernicious anaemia 1 

Pernicious anapmin 2 

Pernicious anaemia 3 

Hemolytic jaundice 1 

Hemolytic jaundice 2| 

Cirrhosis of liver 1 

Cirrhosis of liver 2 

Cirrhosis of liver 3 

Catarrhal jaundice 1 j 

Catarrhal jaundice 2 

Catarrhal jaundice 3 

Obstructive jaundice 1 

Obstructive jaundice 2 

Secondary anemia, carcinomatous stomach . .1 
Secondary anaemia, carcinomatous oesophagus 2 

Nephritis 1 

Nephritis 2 

Polycythemia 

Purpura - 



* Figures are for 1000 c.c. of blood. 

examination of the spleen he found thickened walls in the 
arterioles and intense congestion of the pulp. He assumes, 
therefore, that the blood seeks the path of less resistance 
through Weidenreich's open capillaries into the pulp, where 
they are destroyed, presumably by contact with the con- 
nective tissue. From this rather fantastic point of view, 



268 THE SPLEEN AND ANEMIA 

splenectomy therefore becomes equivalent to tying off a 
ruptured blood-vessel. 

Summary. — The several diseases described in this 
chapter not only have sufficiently characteristic and con- 
stant symptom-complexes to permit a differential diagno- 
sis to be made, but are also, in all probability, due to dif- 
ferent causes, or possibly to a common factor operating 
in different ways. In a strict sense, none of them should 
be considered as primary anaemias, though in some it is 
difficult or impossible to find the " causa causcrum." From 
the aspect of the chief lesion found (namely, the changes 
in the blood), they may be divided into two groups, in 
one of which increased blood destruction and in the other 
impaired blood formation is characteristic. As will be 
shown in a later chapter, the relative importance of these 
features has an important bearing on the results produced 
by transfusion and splenectomy. From this point of view, 
the anaemia of Banti's and Gaucher 's diseases is chiefly due 
to impaired blood formation, while that of the hemolytic 
jaundices is due to impaired blood destruction. Finally, 
in another disease, pernicious anaemia, commonly treated 
by splenectomy, increased haemolysis predominates, but is 
usually accompanied by seriously impaired powers of blood 
formation. 



CHAPTER XII 

METHODS OF VALUE IN THE DIAGNOSIS AND PROG- 
NOSIS OF SPLENIC DISEASE 

The numerous points of resemblance or of slight dis- 
similarity in the several clinical conditions analyzed in the 
previous chapter demonstrate that in a given case careful 
study must usually be made before a proper diagnosis can 
be reached and such studies continued, if the prognosis and 
effect of treatment are to be properly gauged. An impor- 
tant part of these studies is not only the performance of 
certain special tests to be described in this chapter, but also 
the proper accomplishment of the usual history taking, 
physical examination, and routine blood examinations. 

In history taking, emphasis should be laid on a most 
thorough inquiry into the family history for evidence of 
disease of a similar nature, either in the present or former 
generations. Not only should exhaustive search be made 
into the patient's or parents' past histories for possible 
underlying or contributory causes, but also the most prob- 
able time of onset of the disease must be carefully investi- 
gated. Experience has shown that it is in connection with 
these three points that most defective histories are at fault. 
The physical examination should always include careful 
investigation into the presence or absence of jaundice, and 
the size of the liver, spleen, and lymph-nodes. Evidence 
of jaundice should be sought not only in the skin and 
mucous membranes, but by appropriate tests of the urine 

269 



270 THE SPLEEN AND ANAEMIA 

and by inspection of the blood serum.* Frequently re- 
peated routine blood examinations should be made. The 
chief fault in connection with such examinations is that they 
are not repeated often enough, both before diagnosis has 
been reached and while the effect of treatment is being 
studied. 

The special laboratory tests to be described in this 
chapter are all concerned with attempts to study as nearly 
quantitatively as may be both the nature and degree of the 
disease process (estimation of amount of blood destruction, 
changes in the blood-serum and in the resistance of erythro- 
cytes) , and the ability of the body to compensate therefor 
(evidences of blood regeneration). It must, however, 
always be remembered that the constantly changing factors 
of blood destruction and blood regeneration are being dealt 
with, so that conditions may be met with in which: (1) 
Blood destruction is excessive, but powers of regeneration 
well preserved (as in hemolytic jaundice) ; (2) blood de- 
struction excessive and powers of regeneration insufficient 
(as in pernicious and aplastic ansemia) ; (3) blood de- 
struction not excessive, but powers of regeneration insuf- 
ficient (as in Banti's and Gaucher's disease), with an in- 
finite number of intermediate grades. Such considerations 
are further complicated by the fact that the bone-marrow 
response may be considerable, but pathological in type, as 
in remission stages of pernicious ansemia. It must also be 
remembered that, although fairly accurate indirect methods 
exist for estimation of the amount of blood destruction, 

* Blood should be withdrawn from ear or finger-stab into a pointed 
glass tube of small calibre, which is then sealed by heat and allowed 
to stand for several hours. 



VALUE IN DIAGNOSIS AND PROGNOSIS 271 

the study of blood regeneration is still largely qualitative. 
The tests referred to may be considered under the fol- 
lowing heads: 

A. Resistance of erythrocytes. 

B. Evidences of bone-marrow activity (recircu- 

lated cells; nucleated forms, platelets). 

C. Agglutinins and hemolysins in the blood- 

serum. 

D. Urobilin excretion. 

E. Protein, uric-acid and iron metabolism. 

A. Resistance of Erythrocytes to Hypotonic Salt 

Solution 

The resistance (fragility) of erythrocytes to various 
fluids was first studied by Malassez 26T in 1873, and the 
mechanism of the destruction of the red blood-cell has been 
more or less imperfectly understod since the time of Ham- 
burger's 165 investigations on osmosis of body fluids. 
Although hypotonic salt solution in varying strengths has 
been the most commonly used in clinical tests, saponin, 
snake venom, bacterial hsemolysins, and specific hemolytic 
immune serums have also been employed either as clinical 
tests or in attempts to explain the mechanism of the de- 
struction of the erythrocyte. As a general rule, if the re- 
sistance of erythrocytes is increased or decreased to one of 
these agents, it will be so to all, but occasional exceptions 
have been noted. Thus in obstructive jaundice and in 
pernicious ansemia it has been claimed that the resistance 
of erythrocytes to saponin is diminished, whereas it is in- 
creased to hypotonic salt solutions. In our own work, on 
the other hand (see page 42), we have found that in 
animals under various experimental conditions the changes 



272 THE SPLEEN AND ANAEMIA 

in resistance to saponin and hypotonic salt solution were 
always parallel. On account of such possible divergences, 
however, it is advisable, for the present at least, to confine 
routine tests to the hypotonic salt solution method. 

This method depends on the simple principle that ery- 
throcytes can remain for some hours in isotonic salt solu- 
tion without damage, whereas when placed in distilled 
water they are very quickly haemolyzed, the haemoglobin 
being " laked out " of the corpuscular stroma. If, then, 
suitable intermediate strengths of solution are arranged, 
it can be determined in just what strengths of salt solution 
partial haemolysis occurs, and at which point complete 
haemolysis first occurs. The various ways of applying this 
testi have been considered in detail by Ribierre, 370 the 
method finally adopted by him being as follows: Glass- 
ware should be sterilized and the chemically pure sodium 
chloride should be desiccated before preparation of stock 
solutions, to get rid of the " water of interposition." In 
normal cases nine small tubes are arranged in strengths 
varying as follows: 0.50, 0.46, 0.44, 0.42, 0.40, 0.38, 0.34, 
0.32, 0.28 per cent. NaCl. (If it is found that haemolysis 
occurs at 0.50 per cent., a second test is made with solutions 
of the strengths 0.60, 0.56, 0.52. ) The finger of the patient 
is carefully cleansed, pierced in the usual manner, and blood 
sucked into a pipette to a mark denoting one-fiftieth of the 
content of the pipette (about 2 c.c.) . It is then filled with 
the appropriate strength of salt solution, mixed and emptied 
into one of another series of small tubes, avoiding as much as 
possible the admixture of air, and the operation is repeated 
through the series of tubes. These are then covered with 
rubber caps, allowed to stand five minutes, centrifuged for 
one and one-half minutes, and the results observed. Ribierre 



VALUE IN DIAGNOSIS AND PROGNOSIS 273 

has found that, although after twenty- four hours the 
amount of haemolysis is slightly increased, there is no ap- 
preciable difference between a five-minute and a three- 
or four-hour period. Many observers still consider it 
necessary to defibrinate and wash the erythrocytes ; but this 
not only requires greater quantities of blood and consid- 
erably increases the difficulty of the examination, but also 
to a slight extent mechanically injures the cells, so that 
a slightly lessened resistance is found. To be sure, Widal, 
Abrami, and Brule showed that in some cases of the ac- 
quired form of hsemolytic jaundice with apparently normal 
resistance fragility would be demonstrated if the cells were 
washed free of plasma. Later work, however, both in this 
laboratory and elsewhere, has tended to show that any 
change, when present, is in the cells themselves. 

In our work in this laboratory, both on patients and 
animals, the use of a mixing pipette has been found un- 
necessary, the measurement of many drops to each tube 
tedious, and sedimentation for one hour has proved prefer- 
able to centrifugalization. The test is therefore performed 
as follows: 

Stock solutions of sodium chloride are prepared as 
above described in strengths varying by 0.02 per cent, 
from 0.20 to 0.70 per cent. If kept tightly stoppered these 
may be used for several months, but should be renewed 
earlier if control tests show any change in concentration 
of solutions. 

A series of twelve or more tubes containing 1 c.c. of 
different strengths of hypotonic salt solution are then 
arranged, varying by 0.02 per cent, from 0.25 per cent, to 
0.60 per cent, (or even stronger, if diminished resistance 

18 



274 THE SPLEEN AND ANAEMIA 

is suspected) . Into each one drop of whole blood is intro- 
duced and the tube gently shaken. If the drops have been 
of different size, slightly more blood may occasionally have 
to be added until the color is the same in all. After stand- 
ing two hours at room temperature, in the stronger solu- 
tions in which no haemolysis has occurred, the unchanged 
corpuscles at the bottom of the tube will be overlaid with 
colorless salt solution. In the weakest solutions all cor- 
puscles will have been haemolyzed, forming a transparent 
red solution. In the intermediate tubes can be noted 
the point at which haemolysis begins and at which it is 
complete. 

In normal cases haemolysis begins at about 0.45 and is 
complete at 0.35 per cent. In a case of the familial type 
recently examined haemolysis began as high as 0.7 per 
cent, and was already complete at 0.475 per cent. In most 
other anaemias the resistance is nearly always more or less 
increased, depending on the severity of the anaemia. 
Haemolysis may not begin until solutions as low as 0.36 are 
reached, or may not be complete before 0.24 or 0.26 per 
cent. In pernicious anaemia, while the resistance is usually 
greatly increased, cases have been reported in which the 
resistance is normal or even diminished, so that there is a 
marked resemblance to haemolytic jaundice. 

B. Evidences of Bone-Marrow Activity 
1. By Vital Staining. Skeined or Reticulated Cells. — 
Amidst the confusion that surrounds the subject of stain- 
able granules in the erythrocytes, a few facts are generally 
accepted by haematologists. One such is that a basophilic 
reticulation is demonstrable by the methods of vital stain- 



VALUE IN DIAGNOSIS AND PROGNOSIS S75 

ing in a very small percentage of normal cells, but in 
greatly increased numbers in various diseased conditions 
of the blood. This special method of examination was 
first described by Chauffard and Fiessinger,™ in 1907, in 
connection with their study of a case of congenital hsemo- 
lytic jaundice, in which condition the reticulated (granu- 
lous or skeined) erythrocytes are very much increased. 
These authors used Pappenheim's pyronine methyl green 
stain (equal parts of saturated aqueous solutions of pyro- 
nine and methyl green, prepared at least several days 
before use, and filtered just before using), but also sug- 
gest the use of neutral red in isotonic solution, while Widal 
recommends polychrome methylene blue, and we have 
found the best results with brilliant cresyl blue. 

This simple test is performed as follows : A few grains 
of the stain are dissolved in a perfectly clean, small test- 
tube in 1 c.c. of normal salt solution, together with one or 
two small crystals of potassium oxalate, to prevent rou- 
leaux formation.* As the exact strength of the solution 
is immaterial, it is sufficient to prepare the stain in this way, 
aiming to get a strength of solution that is just translucent 
in a test-tube of 1 cm. diameter. A few drops of blood are 
allowed to flow into this tube, the mixture gently shaken 
and allowed to stand ten or fifteen minutes. A drop of 
the sediment is then pipetted off, a fresh cover-slip prepa- 
ration made and examined under an oil immersion lens. 
The blue-staining reticulum is easily visible under such 
conditions, and the percentage of reticulated to non-reticu- 
lated erythrocytes estimated. The protoplasm of the ery- 
throcytes is not affected by the stain, whereas the various 

* The solution of sodium oxalate in salt solution may be prepared 
beforehand and kept on hand, if the test is made frequently. 



276 THE SPLEEN AND ANEMIA 

forms of leucocytes, the platelets, and hsemokonium are 
readily stained and identified. The average diameter of 
the reticulated cell, according to Chauffard and Fiessinger, 
is 8.1/*, as compared with an average diameter of 6.3/* for 
the non-reticulated cell. 

The reticulum persists longer than the protoplasm of 
the erythrocyte under the conditions of this test, but the 
majority of both will disappear in the course of a few 
hours. If an accurate comparative count is to be made, the 
cover-slip should be prepared and examined between fifteen 
and thirty minutes of the time of obtaining the blood. 

In the blood of normal human subjects, reticulated 
erythrocytes are either entirely absent or constitute but 
a very small fraction of one per cent. They tend to be 
slightly increased in any considerable ansemia, but rarely 
exceed 1 to 4 per cent. Thus Chauffard and Fiessinger 
found an average of one cell in 500 and one in 400 in cases 
of tuberculosis, one in 400 and one in 600 in mitral disease, 
one in 600 in malaria, one in 500 in plumbism, one in 200 
in chronic nephritis, and one in 100 and one in 50 in plumb- 
ism with nephritis. In a case of tuberculous nephritis with 
profound ansemia, subicterus, and diminished resistance 
of erythrocytes, the reticulated forms were considerably 
increased (2 per cent.). In cases of hemolytic jaundice, 
on the other hand, the percentages of reticulated forms 
reach as high as 15 to 20 per cent., and in the case reported 
in the previous section of this book (page 202) the counts 
were frequently above 5 per cent. The proportion of 
reticulated cells varies considerably in different species, 
these cells in the normal dog being even rarer than in man, 
whereas in the rabbit they constitute about 2 per cent, of 
the total number. 



PLATE IX 




Reticulated red blood-cells. From a case of hseinolytic jaundice 



VALUE IN DIAGNOSIS AND PROGNOSIS 277 

The nature of the reticulated erythrocytes has not yet 
been demonstrated, but whether the reticula are nuclear 
fragments of immature erythrocytes, indicating a bone- 
marrow reaction (as has been generally considered), or 
are the results of a disease process, their identification is 
of great diagnostic value, and their diminution or disap- 
pearance as the result of treatment may be taken as a sign 
of good prognostic significance. 

2. By Fixed Smears (Nucleated forms, Howell- Jolly 
bodies, etc. ) . — Although no direct method exists of deter- 
mining the rate of blood formation, it may be considered 
as equal to blood destruction (as estimated from urobilin 
excretion, etc.) so long as the blood counts remain con- 
stant. Although even this method fails if the count is rising 
or falling, nevertheless under all conditions some criteria 
exist for estimating the effort required of the blood-form- 
ing organs (mainly bone-marrow) to maintain the cellular 
elements of the blood at the level they happen to be. Thus 
in the stained dried smear of the peripheral blood, stained 
with any of the Romanousky group of stains, the presence 
of nucleated forms may be taken as evidence that the bone- 
marrow is so hard pushed that it must allow T immature 
forms to appear in the peripheral blood. If the nucleated 
erythrocytes are megaloblasts, the diagnosis of pernicious 
anaemia is strongly suggested, but it must not be forgotten 
that other chronic anaemias, particularly those in which 
small hemorrhages occur over long periods of time, can 
also produce megaloblasts in the peripheral circulation. It 
must also be remembered that in certain rare conditions, 
such as tumors of the bone-marrow, erythroblasts may 
appear in the peripheral circulation without indicating 
excessive blood regeneration. 



278 THE SPLEEN AND ANAEMIA 

Howell-Jolly bodies and the Cabot ring forms should, 
like the reticulated forms, be taken as evidence of the de- 
mand on the bone-marrow for increased blood formation 
and of its ability to respond to the same. The increased 
number of these and of nucleated forms after blood trans- 
fusion or splenectomy (so-called " blood crisis ") are simi- 
larly taken as the response to the bone-marrow stimulation 
that these operations cause. These so-called " blood 
crises" will be considered again in the chapter on the results 
of splenectomy under the heading of " Pernicious Anae- 
mia," in which condition they have been most carefully 
studied; but it should be noted that they have also been 
observed after splenectomy in Banti's disease, hemolytic 
jaundice, and other conditions. If absent after splenec- 
tomy when the blood count is rising (as in Goldschmidt, 
Pepper, and Pearce's case), it would indicate that, with 
the cessation of increased haemolysis, the bone-marrow is 
no longer forced to put forth immature forms. If, on the 
other hand, both blood crisis and improvement in blood 
count are wanting, it would indicate that an exhausted 
bone-marrow is no longer capable of responding to stimu- 
lation with the production of even these immature forms. 

The blood crisis, which so frequently follows splenec- 
tomy for splenic disease, has been shown in Chapter II to 
be practically absent after removal of the normal spleen. 
This apparent discrepancy is similar to the fluctuations 
in the red blood-cell count after splenectomy, which falls 
after removal of the normal spleen, but rises after splenec- 
tomy in splenic disease. The most probable explanation 
of both paradoxes seems to be that in disease the improve- 
ment is due to the removal of an agent which both causes 
excessive haemolysis and depresses bone-marrow function, 



VALUE IN DIAGNOSIS AND PROGNOSIS 279 

whereas the anaemia following normal splenectomy is due 
to loss of normal stimulus to blood formation, and, for the 
same reason, unusual signs of bone activity are lacking. 

Polychromatophilia, like the presence of microcytes 
and poikilocytes in the blood stream (Rous) 387a probably 
indicates degeneration of the erythrocyte rather than the 
appearance of immature forms. Macrocytes, like megalo- 
blasts, are probably signs of perverted bone-marrow activ- 
ity. The diminution or increase of the number of such 
forms, may, however, safely be taken as indicative respect- 
ively of amelioration or aggravation of the disease process. 

3. Blood Platelets and Leucocytes. — If Wright's 
theory be accepted, that the blood-platelets are independent 
elements of the blood formed from the megakaryocytes of 
the bone-marrow, both leucocytes and platelets 478 enter 
into the problem of blood regeneration. The leukopenia 
and the diminished platelet counts found in many of the 
diseases here under consideration should therefore be taken 
as further evidence of deficient blood formation. The 
increase in blood-platelets observed by Lee, Vincent, and 
Robertson 241 after splenectomy, may therefore be con- 
sidered another factor in the " blood crises " previously 
described. In disease conditions a gradual change in these 
elements of the blood in the direction of normal figures 
should also be taken as a sign of improvement, though not 
necessarily of permanent improvement. 

C. Agglutinins and Hemolysins in the Blood-serum 
1. Auto- agglutinins, — A simple test that Widal, 
Abrami, and Brule 471 have found of value in differentiat- 
ing the congenital and acquired types of hemolytic jaun- 
dice is that suggested by Brule after the method of Pagniez 



280 THE SPLEEN AND ANAEMIA 

for the presence of auto-agglutinins in the serum. This 
test consists merely of mixing one drop of the patient's 
washed red blood-cells with ten drops of the patient's own 
serum in a watch-glass. If positive, after some seconds, 
the mixture loses its Homogeneous aspect, visible granules 
of agglomerated corpuscles are evident on agitating, and 
finally, after several minutes, a distinct pellicle forms that 
sinks to the bottom and does not mix with the clear serum 
on shaking. In doubtful cases the result can be confirmed 
by microscopic examination. Widal, Abrami, and Brule 
found this test intensely positive in three cases of acquired 
haemolytic and negative in two cases of the congenital type, 
and also negative in cases of alcoholic cirrhosis, simple 
catarrhal jaundice, and other conditions. They state that, 
while " iso-agglutination " (agglutination of corpuscles by 
serum of subjects of the same species) is frequently ob- 
served (60.9 per cent, of cases, according to Pagniez), 
auto-agglutination is, so far as they know, never positive 
except in this condition. 

2. Autolysins, Isolysins, and Heterolysins. — The hae- 
molytic power of the patient's serum may be tested on 
his own blood-corpuscles (autolysis), on the corpuscles of 
other human blood (isolysis), or on the corpuscles of an- 
other species (heterolysis) (see Widal and Wiessen- 
bach 472 ). To twenty drops of the patient's fresh serum 
is added one drop of washed red blood-corpuscles from 
the appropriate source. The mixture is incubated at 37° 
for thirty minutes and the existence and degree of haemo- 
lysis noted in the color of the supernatant fluid. Tests 
for heterolysins are of little value, as they are frequently 
present in normal sera. Comparative tests may be made 
with tubes containing different amounts of the patient's 



VALUE IN DIAGNOSIS AND PROGNOSIS 281 

serum and the results compared with those in similar tests 
of known normal blood. While positive tests for auto- 
lysis have, so far as I know, never been reported, Chauf- 
fard, Widal, and Weissenbach and others have reported 
cases that at times of exacerbation of the disease give a 
positive " isolysin " test, indicating the presence in the 
serum at these times of a free hemolysin. During periods 
of remission these isolysins were not found. It must, of 
course, be remembered that Moss 303a and others have 
found that the blood of a certain percentage of individuals 
is normally isolytic and isoagglutinative to the blood of 
other individuals of the same species. 

D. Urobilin Excretion 

It is now generally recognized that in the estimation 
of the amount of urobilinogen and urobilin excreted in 
the urine and stools there exists a fairly accurate index 
of the amount of blood being destroyed in the body. 
Emphasis has been laid throughout this book on the impor- 
tance of the study of blood destruction in its relation to 
the spleen, and it is Eppinger's 104 great service to have 
brought us to recognize the importance of urobilinogen 
and urobilin excretion in the stool as the best index of 
such destruction. Instead of such indefinite criteria as an 
enlarged spleen, tendency to acholuric jaundice, or the 
existence of anaemia coincident with active blood formation, 
Eppinger was led to search for a more definite index, and 
found it in Charnas's spectroscopic method for the quanti- 
tative estimation of the amount of urobilinogen and uro- 
bilin in the stool. Although this has been generally re- 
placed by the Wilbur and Addis 473 method, it still remains 
only roughly quantitative and a rather disagreeable and 



282 THE SPLEEN AND ANiEMIA 

time-consuming test, so that improved methods are still 
to be hoped for. Emphasis must be laid, however, on the 
fact that examination of the stool as well as the urine 
is essential; for, while urobilin is more apt to be present 
in the urine when there is an increased amount of blood 
destruction than in normal conditions, this is in the nature 
of an overflow through the liver, and may be absent when 
there are still greatly increased amounts in the stool ; and, 
furthermore, the amount of urobilinuria may be influenced 
by a poorly functioning liver. 

Method. — The method for estimating the amount of 
urobilinogen and urobilin in the stools is described by 
Wilbur and Addis as follows : 

URINE 

" The method of collection of the twenty-four-hour 
urine has a considerable effect on the total spectroscopic 
reading. The vessel in which the urine is collected should 
be of dark-brown glass and should be kept in darkness. 
Thymol crystals should be added, for, even in cases in 
which no obvious fermentation had occurred, we sometimes 
found a diminution in the total amount if no preservative 
was present. After measuring the amount of the twenty- 
four-hour urine, 10 c.c. are mixed with 10 c.c. of a saturated 
alcoholic solution of zinc acetate and, after a few minutes, 
filtered. If a number of urines are being examined at the 
same time, it is convenient to have test-tubes graduated to 
10 and 20 c.c. Ten cubic centimetres of the filtrate are 
taken and 1 c.c. of Ehrlich's solution* is added. It was 
found that this amount produced a sufficient concentration 

* Paradimethylaminobenzaldehyde, 20 gm. ; concentrated hydro- 
chloric acid, 150 c.c; water, 150 c.c. 



VALUE IN DIAGNOSIS AND PROGNOSIS 283 

of acid in the mixture to give the maximum intensity of 
the urobilin band and contained enough of the paradi- 
methylamidobenzaldehyde for the reaction with urobilino- 
gen. The development of the urobilinogen band is not 
instantaneous. We found that, as a rule, it had attained 
its full intensity in a quarter of an hour. The action can 
be greatly accelerated by heating, but this is to be avoided. 
It is better to wait for an hour before making the reading, 
and during this time the solution should be kept in the 
dark. After three or four hours there is a diminution of 
the urobilin and urobilinogen in filtrates from urines, so 
the estimation should be made not later than three hours 
after adding the Ehrlich solution. We found that Citron's 
hand spectroscope * was the most convenient instrument 
to use. The filtrate was washed into a graduate and diluted 
with tap-water until first one and then the other band of 
light absorption had disappeared when the full amount of 
light entered the spectroscope, but were still visible when 
the light was partly shut off. This gives a fairly definite 
end-point, and we did not find any great variation in the 
readings made by different persons. It is important, of 
course, that the light shall be always of approximately 
equal intensity. We made the readings in a dark room 
with a tungsten electric bulb, holding the spectroscope 
close to the source of light. In highly-colored urines one 
may be in doubt as to whether or not a trace of urobilin is 
present, for there may be so much general absorption of 
light as to obscure the urobilin band in the undiluted fil- 
trate. There is no such difficulty with the urobilinogen 
band, which lies between the red and yellow where there 

* This can be obtained from Paul Altmann, Luisenstrasse, Berlin, 
Germany. 



284 THE SPLEEN AND ANAEMIA 

is no marked light absorption. With urines containing bile, 
if the amount of urobilin is not very large, it is necessary to 
add some fuller's earth and to leave the mixture standing 
for some time before filtration. If this is done the urobilin 
band can usually be read even in the undiluted nitrate. 
The dilution required gives the value for 5 c.c. of urine. 
If this figure is multiplied by the number of 5 c.c. quan- 
tities in the twenty-four-hour urine, the number of dilu- 
tions which would have been necessary if all the urobilino- 
gen and urobilin in the twenty-four-hour amount had been 
concentrated in a volume of 5 c.c. is obtained. For in- 
stance, if in a twenty-four-hour urine measuring 1000 c.c. 
a reading of ten dilutions for urobilinogen and of 
twenty for urobilin were made, the total urobilin would 
be 30 X 200 = 6000. We tried to determine the dilution 
value of definite weights of urobilin prepared from biliru- 
bin, but different preparations varied so much in their 
dilution value that it was obvious that we were not dealing 
with pure urobilin, and we abandoned any attempt to ex- 
press our results in milligrammes of urobilin. 

STOOLS 

"All the fasces passed in the twenty- four hours were 
collected in the same receiver, the stools being protected 
from light. They were then washed into a large graduate 
and thoroughly ground up with water into a homogeneous 
paste, and water added to 0.5, 1, or, if necessary, 2 litres, 
depending on the quantity of stool. After thorough mix- 
ing, 25 c.c. were taken and 75 c.c. of acid alcohol (95 per 
cent, alcohol, 1600 c.c; concentrated hydrochloric acid, 
25 c.c, and water, 800 c.c.) were added. The mixture was 
then put into a shaker for about half an hour. A consid- 



VALUE IN DIAGNOSIS AND PROGNOSIS 285 

erable number of extractives were tried for removing the 
urobilin from the stools, but none were found so efficient 
as alcohol with hydrochloric acid. After thorough mixing 
in the shaker, an equal quantity of a saturated solution of 
zinc acetate in alcohol was added and the mixture was 
filtered. After adding 2 c.c. of Ehrlich's reagent to 20 c.c. 
of the filtrate, the solution was put aside in a dark place 
until next day. The addition of zinc acetate is not abso- 
lutely essential, but in some cases we observed an intensi- 
fication of the urobilin band following its use, and it is 
perhaps an advantage to make the urine and stool readings 
so far as possible under the same conditions. The de- 
velopment of the urobilinogen band was not always com- 
plete until six hours had elapsed, but thereafter there was 
no loss of urobilinogen or urobilin for a long time, although 
this was not the case with the zinc acetate filtrates before 
the addition of Ehrlich's solution. The reading was made 
in the same way as with the urine and the total amount 
calculated for the volume of stool after grinding up with 
water, the dilution of the 25 c.c. by acid alcohol and zinc 
acetate being taken into account. Instead of using tap- 
water for dilution of the final extract, 60 per cent, alcohol 
was required to avoid the development of a precipitate." 

Wilbur and Addis found that, while urobilin is a nor- 
mal constituent of the urine, the amount is so small that 
ordinarily it can be demonstrated only by extracting large 
quantities of urine. A positive result, therefore, in twenty- 
four-hour specimens indicates an abnormal increase over 
the amounts usually present. In the stools of ten adults 
with supposedly normal haemoglobin metabolism they found 
that the average daily excretion of urobilin varied between 



286 THE SPLEEN AND ANAEMIA 

3307 and 8737 dilution values, with a general average of 
6475. It is important, however, to note that, on account 
of the wide daily fluctuations, examinations of single 
twenty-four-hour specimens are of little value. So long 
as stools were kept from exposure to light there did not 
seem to be a very rapid loss of urobilin, and, as the desired 
figures represent the combined value of urobilinogen and 
urobilin, the amount of the former that changes to the latter 
while standing is immaterial. In making comparative 
studies, however, as for example before and after splenec- 
tomy, it is advisable to make examinations as nearly as 
possible after equal amounts of time have elapsed since the 
collection of the material. While Wilbur and Addis were 
not able to demonstrate urobilin in the blood- serum with 
certainty, they found their method was applicable to the 
study of the bile, but that widely-varying figures were 
obtained. Thus in sixteen diverse cases, unconnected with 
excessive blood destruction, 10 c.c. of bile, obtained post- 
mortem, yielded dilution values varying between and 
4500. As will be shown later, this finding constitutes a 
strong objection to the duodenal tube method of Schneider. 
In applying their method to various clinical conditions, 
Wilbur and Addis found very high average figures in 
the stools of cases associated with increased blood destruc- 
tion. That this finding may be useful in diagnosis is shown 
by the fact that, whereas two cases of pernicious anaemia 
had average figures of 22,014 and 24,977 respectively, a 
case of secondary anaemia showed an average of only 2400, 
The value of this method in prognosis and in studying 
the results of treatment is shown in the following 
paragraphs. 



VALUE IN DIAGNOSIS AND PROGNOSIS 287 

By Charnas's method, Eppinger found that the normal 
adult excretes from 0.12 to 0.15 gm. of urobilin per day, 
and that these figures were not materially increased, or 
were even diminished in such secondary anaemias as those 
of carcinoma, Addison's disease, post-abortive ansemia, and 
chlorosis. In cases where there was excessive blood de- 
struction, on the other hand, these figures were greatly 
increased. In pernicious ansemia, for instance, he found 
such figures as 0.24 gm., 0.58 gm., and 1.14 gms. per day, 
and in three cases of hsemolytic jaundice the enormous 
increase of 1.75 gms., 2.59 gms., and 3.95 gms. per day. 
McKelvy and Rosenbloom 262 also found increased urobilin 
excretion in a case of hsemolytic jaundice. In a case of 
pernicious ansemia submitted to splenectomy, Eppinger 
found that the increased urobilin excretion was diminished 
to mere traces after operation, and one of the cases of 
hsemolytic jaundice, which excreted before operation 2.96 
gms. to 3.95 gms. daily, after splenectomy excreted only 
0.062 and 0.70 gm. daily. 

These findings have been confirmed by Robertson, 378 
and also by work from this department (see page 202). 
Robertson emphasizes the fact that cases which had shown 
a high urobilin excretion before splenectomy, and in which 
after splenectomy the urobilin output exhibited only a 
transient reduction, or none at all, did not show as much 
improvement in other respects following the operation as 
did those cases in which the urobilin output was perma- 
nently reduced after splenectomy. The cases of pernicious 
ansemia and of congenital hsemolytic jaundice studied in 
this department before and after splenectomy have been 
treated in detail in a previous chapter. In this connection, 



288 THE SPLEEN AND ANAEMIA 

however, it should be noted that splenectomy produced a 
definite improvement in the combined urobilinogen and 
urobilin excretion in both of these cases. In the case of 
pernicious anaemia before splenectomy the urobilin figure 
(by the Wilbur and Addis method) averaged 18,300 per 
day. Two weeks after splenectomy this figure averaged 
16,000 per day, a diminution too slight to permit of sig- 
nificance being attached to it. Two months after splenec- 
tomy, however, at a time when the blood count showed a 
pronounced and most satisfactory improvement,: the uro- 
bilin output had fallen to one-seventh of its former figure 
and had reached a low normal elimination. In the case of 
congenital hemolytic jaundice, urobilin was never found 
in the urine. In the stools, however, the dilution required 
for extinction of urobilinogen and urobilin absorption 
bands (Wilbur and Addis method) > over two periods 
totalling ten days before splenectomy was 71,250; whereas 
for two periods totalling eight days after splenectomy the 
figures were only 7954. 

Schneider 396 has recently shown, by a method of his 
own devising, that a quantitative estimate may be made 
of the urobilin, urobilinogen, and bilirubin in the duodenal 
contents, obtained through a duodenal tube. He confirms 
previous work in finding all the above elements increased 
in pernicious anaemia and diminished or absent in other 
conditions simulating pernicious anaemia. He considers 
the pleochromia found to be an expression of the immediate 
haemolysis, urobilinocholia an expression of the heaped- 
up pigment in the portal system, and the high color-index 
of the blood in pernicious anaemia an expression of the 
overplus of haemoglobin-building material heaped up in 
the liver. Examination of a single specimen, as practised 



VALUE IN DIAGNOSIS AND PROGNOSIS 289 

in this method, however, even though the substance sought 
for may be in greater concentration, is so much less de- 
sirable than examination of the total collection of several 
days, as in the stool method, that it is doubtful whether 
this procedure will prove as useful as the Wilbur and 
Addis test, cumbersome and disagreeable as the latter 
may be. It has already been pointed out, also, that Wilbur 
and Addis found extremely wide variations in the urobilin 
content of bile, and that there is evidence to show that the 
daily output of urobilin varies greatly in a given indi- 
vidual. Although the stool method fails to take account 
of the urobilin reabsorbed by the intestine, this disad- 
vantage is probably more than counterbalanced by weak- 
nesses in the duodenal method, which ignores variations in 
the composition of the bile and estimation of the total 
quantity of bile secreted, and also is more liable to errors 
in the collection of material. 

E. Protein, Uric-acid, and Iron Metabolism 

Expression of the need for proper metabolic studies in 
the diseases considered in this book, the best methods for 
studying the same, and the results hitherto obtained, both 
experimentally and clinically, will be found in detail in 
Chapters VIII and X. In spite of the fact that discor- 
cordant results are there recorded, both in clinical and ex- 
perimental work, a few facts of value to the clinician may 
safely be deduced. In severe ana?mias an increased elimi- 
nation of uric acid and iron is found, and Umber's work 
demonstrates a pathologically excessive destruction of pro- 
tein in some cases of Banti's disease. As all these con- 
ditions of metabolism improve after splenectomv, cases 

19 



290 



THE SPLEEN AND ANAEMIA 



showing such disturbance of metabolism should probably 
be considered especially suitable for splenectomy. A final 
decision on this point, however, cannot be reached until a 
larger number of metabolic studies are at hand, and for 
this reason it is desirable that complete studies of this kind 
should be made whenever conditions are favorable. 



CHAPTER XIII 

TREATMENT OF SPLENIC DISEASES BY METHODS 
OTHER THAN SPLENECTOMY 

(1) BLOOD TRANSFUSION. (2) MEDICINAL AND HY- 
GIENIC MEASURES. (3) SURGERY OTHER THAN 
SPLENECTOMY. 

In the treatment of certain phases or of individual cases 
of splenic disease, splenectomy must either be postponed 
or be considered as definitely contra-indicated. For in- 
stance, in very late stages of Banti's disease or in pernicious 
anaemia, in periods of exacerbation with extreme anaemia, 
or in the crises of deglobulization of the haemolytic jaun- 
dices recourse to splenectomy may be impossible. At the 
other extreme of the scale, some cases of familial jaundice, 
" more icteric than sick," are so little incommoded by the 
disease that splenectomy may be considered unnecessary. 
In these, as in other cases where the operation must be 
postponed, or even in relapses after splenectomy has been 
performed, certain other procedures have considerable 
value. 

1. Blood Transfusion. — The most important of these 
is the method of multiple blood transfusions, which, on ac- 
count of the simpler methods of technique now in use, both 
for detecting suitable donors and for the actual transfusion, 
has now come into widespread use. 

Technique of Tests for Haemolysis and Agglutina- 
tion. — Lindeman's 249 method of testing the suitability of 
donors is as follows: " The red blood-cells of patient and 
donor are washed three times with normal saline ; varying 

291 



292 THE SPLEEN AND ANAEMIA 

quantities of patient's serum are placed in three separate 
small test-tubes. To each of these are added 0.25 c.c. of 
a 2 per cent, suspension of washed red blood-cells of the 
donor. The same is done with the donor's serum and the 
patient's cells. Controls are made of donor's serum and 
donor's cells — patient's serum and patient's cells. Con- 
trols are also made with donor's cells in normal salt solution 
and patient's cells in normal salt solution. The total vol- 
ume in each tube is raised with normal saline to 0.5 c.c. of 
volume. The test-tubes are incubated in a water-bath for 
a period of two hours, and readings are made. They are 
then set in the ice-box over night and readings are made 
again the following morning. When a case is urgent, the 
ice-box test is eliminated. The ice-box test should be elimi- 
nated only when absolutely necessary by the extreme con- 
dition of the patient, where time is the important factor. 
When the amount of blood taken from the patient for tests 
is small, only 0.25 c.c. of serum is used, and controls of 
patient's serum are eliminated." A Wassermann test of 
the donor's blood should, whenever possible, be included. 
This and the subdivision of the donor's blood into the 
proper agglutination groups may readily be done, if the 
practice is followed of having in reserve a list of pros- 
pective donors ready to donate blood on demand. 

In 146 cases in which tests by this method were per- 
sonally supervised byLindeman"not a single case of haemo- 
lysis and not a single death referable to the transfusion 
occurred. The necessity for careful performance of the 
test is shown by the fact that chills occurred in only thir- 
teen instances (9 per cent.) , whereas in nine cases in which 
the tests were not personally supervised chills occurred in 
five instances (55 per cent.)." 



TREATMENT OF SPLENIC DISEASES 293 

Minot 292 has shown that if one has on hand serum 
and corpuscles of subjects belonging to Groups II and 
III (of Moss's four groups), the group to which an adult 
patient belongs may be determined in twenty minutes. If 
then donors are available that have been previously cata- 
logued according to groups, transfusion may be performed 
without danger. 

The test is performed as follows : A suspension of red 
cells from the patient is " obtained by collecting one drop 
of blood in about 1 c.c. of a 1.5 per cent, of citrate solution 
in 0.9 per cent, salt solution." A drop of this suspension 
is mixed separately with a drop of each serum (which re- 
tains its agglutinating power for months), and allowed to 
stand fifteen or twenty minutes. The presence or absence 
of agglutination is then observed microscopically. Similarly 
a drop of the patient's serum is mixed separately with a 
drop of suspension of corpuscles known to belong to 
Groups II and III, and treated as above described. Minot 
also points out that haemolysis does not always occur in 
vivOj when donor and recipient belong to different iso- 
agglutination groups, because only about 20 per cent, of 
sera that are agglutinative are hemolytic. Haemolysis, 
however, never occurs without being preceded by or asso- 
ciated with agglutination. " Even when donor and patient 
belong to the same iso-agglutination group, however, there 
may occur, after transfusion, reactions of unknown nature, 
which are probably of not so severe or serious a nature as 
haemolysis." 

While the technique of the various methods of trans- 
fusion now in use cannot be considered here, suffice it to say 
that, with proper precautions, untoward accidents may be 
practically eliminated and excellent symptomatic results 



294 THE SPLEEN AND ANAEMIA 

usually obtained. In all the chronic anaemias under con- 
sideration, not only is the degree of anaemia greatly les- 
sened after transfusion, but in pernicious anaemia especially, 
a bone-marrow reaction, similar to the " blood crisis " fol- 
lowing splenectomy, is apt to occur four to ten days after 
transfusion. Such a reaction " furnishes the most favor- 
able time to do a splenectomy in those cases which have 
been transfused in preparation for the operation " (Vin- 
cent) 454 and frequently initiates in pernicious anaemia a 
remission of from three to twelve months. It might then 
be asked : Why not continue to transfuse instead of having 
recourse to a major operation such as splenectomy? Un- 
fortunately, (1) the benefit is probably of shorter duration 
than is the benefit conferred by splenectomy; (2) in some 
cases improvement becomes less and less after each trans- 
fusion, and (3) the increased blood destruction, as shown 
by urobilin excretion, is not lessened as it is by splenectomy. 
In a study of 212 blood transfusions in 189 cases, Otten- 
berg and Libman 325 discuss at length the various condi- 
tions in which transfusion is indicated. Although the best 
results were found in such conditions as simple hemorrhage, 
hemorrhagic diatheses, and acute poisoning, improvement 
was also noted in various infections, debilitated conditions, 
and in the chronic primary anaemias. In twenty-five trans- 
fused cases of pernicious anaemia, " fourteen underwent 
more or less prolonged remissions immediately following 
transfusion, and eleven showed little or no effect. Of 
these eleven, three were moribund at the time of trans- 
fusion and died within a few hours or days. The other 
eight, in spite of marked rise of haemoglobin and temporary 
symptomatic improvement, showed no interruption in the 
course of the disease, but continued to show blood destruc- 



TREATMENT OF SPLENIC DISEASES 295 

tion of about the same rate as before transfusion. Of the 
fourteen patients who showed progressive improvement 
following one or more transfusions, one had a remission 
lasting approximately three months, three had remissions 
lasting six or more months, three lasting a year or more, 
and three lasting over two years." In spite of the remis- 
sions that are known to occur spontaneously in pernicious 
anaemia, a record such as the above leaves but little doubt 
as to the value of blood transfusion in this condition. For- 
merly when the technique of whole blood transfusions was 
difficult single large doses were employed, but with the 
simpler methods now in vogue repeated transfusions of 
400 to 600 c.c. are considered preferable in the chronic 
anaemias. Not only is the desired amount of blood easier 
to obtain and the discomfort to the donor lessened, but also 
the danger of hypertransfusion is avoided and the indi- 
cations about as well met as when larger doses are used. 
As many as fourteen transfusions have been employed 
with benefit in chronic conditions (McClure 259 ) . It must 
be recognized that in some refractory cases the later trans- 
fusions in a series have done more good than the earlier 
ones ; but it is usually true that if the procedure has failed 
in the first instance, it will probably continue to do so in 
the future, but is less apt to do so if a different donor is 
used. From a study of seven cases of pernicious anaemia 
which had been splenectomized and later transfused, Vogel 
and Downes gained the impression that the subsequent 
effects of transfusion were more marked and persisted 
longer in such cases than in those in which splenectomy 
had not been performed. 

It would therefore seem that in pernicious anaemia, if 
signs of increased haemolysis are present, transfusions 



296 THE SPLEEN AND ANEMIA 

should be employed until the patient is in the best condi- 
tion to submit to splenectomy; and again after splenec- 
tomy, when the effect of the operation has passed away. 
If, on the other hand, the case is of the steadily progressive 
type, unsuitable for splenectomy, transfusions may be 
employed as a palliative measure, according to the state 
of patient's condition and purse. In the various " indirect 
methods " ( syringe, Erlenmeyer flasks, citrated blood, 
etc.) the amount of blood transfused can be accurately 
measured, but even in the " direct " methods an approxi- 
mate estimate of the amount of blood received may be 
obtained by accurately weighing the patient before and 
after transfusion. 

2. Medicinal and Hygienic Measures. — Medicinal and 
hygienic measures to be employed in the treatment of the 
diseases under discussion are the usual remedies for ansemia, 
such as iron, arsenic (salvarsan) , improved general hygiene, 
and an ample but simple, nutritious diet. Conflicting re- 
sults have been reported from X-ray treatment of the 
spleen, but it is possible that properly graded doses may be 
of distinct value. It is almost superfluous to add that in 
cases of splenomegaly with ansemia, where a causative factor 
such as malaria, lues, uncinariasis, etc., is known to exist, 
appropriate medication is all-important. Up to a few 
years ago, before splenectomy and blood transfusions came 
into vogue in the treatment of chronic anaemia, various 
medicinal remedies were reported as of value. Organo- 
therapy (spleen and bone-marrow feeding, ChaufFard, 
Widal) and cholagogues (ChaufFard, Cavazza 68 ), proved 
of but little help, and only with a long-continued course of 
high iron diet did Widal find any marked improvement. 
On account of the antihsemolytic properties of arsenic 



TREATMENT OF SPLENIC DISEASES 297 

(Gunn and Feltham 1G0 ), cholesterin (Chauffard and Gri- 
gaut, 74 Parisot and Heully 328 ), and calcium chloride 

( Iscovesco 194 ) , these drugs have been tried, in some cases 
with considerable improvement. 

On the whole, however, it must be recognized that in the 
so-called primary anaemias medicinal treatment is at best 
palliative, and in most cases unsatisfactory, if relied upon 
for more than a short period. 

3. Surgery other than Splenectomy. — A few surgical 
measures other than splenectomy have been employed in 
these conditions, but may be dismissed in a few words. 
Chauffard and Troisier, 75 Marchiafava and Xazari 27<5 
attempted to influence hemolytic jaundice by various sur- 
gical attempts on the bile-passages, but their failures are 
to-day only of historical interest. A peculiar operation, 
designed to diminish splenic function by squeezing the 
organ in new- formed connective tissue, is recommended by 
Schiassi, 393 under the term " splenocleisis," for cases in 
which splenectomy could not be performed. The capsule 
of the organ is scarified, and wrapped with iodoform gauze, 
which is later gradually withdrawn. Destruction of the 
spleen by gradual cauterization, after fixation to the ab- 
dominal wall, has also been suggested, but the field for 
such a procedure would seem to be extremely limited and 
the chances of success not very great. In similar cases 
Troell 441 recommends, on the basis of experimental work 
similar to that done in this laboratory (page 121) , ligation 
of the splenic arteries and veins. Lanz 23T found ligation 
of the artery beneficial in three cases of wandering spleen, 
but Roblee 38 ° states that out of six cases in which ligation 
was tried by Dr. Skel (discussion of Harris and Herzog's 
paper 169 ) , four died. Although there is no theoretical or 



298 THE SPLEEN AND ANAEMIA 

experimental reason for such high mortality, this operation 
must still be considered to be in the experimental stage. 

The most promising results from surgical measures 
other than splenectomy are to be found in the recent studies 
of Percy 344 on the effects of removing chronic sources of 
infection in cases of pernicious anaemia in which the spleen 
is also removed. He found in pernicious anaemia not only 
that chronic inflammation may frequently occur in the gall- 
bladder, appendix, and other organs, as well as in and 
about the spleen itself, but also that the same strains of 
bacteria may frequently be cultivated both from the spleen 
and the other organ or organs involved. In the hope that 
a possible cause or contributing factor to pernicious ansemia 
may thus be eliminated, he therefore routinely removed 
gall-bladder, appendix, tonsils, or carious teeth, or as many 
as showed signs of chronic infection, either simultaneously 
with the spleen or as soon thereafter as was practicable. 
Even the energetic treatment of a complicating pyorrhoea 
has apparently reinforced the improvement caused by sple- 
nectomy. Of twenty-four cases treated in this way, 
twenty-one showed a marked postoperative improvement, 
and fourteen of these have still continued in their improved 
conditions over periods lasting from eight to thirty-one 
months. In view of these excellent results and as long as 
the cause of pernicious anaemia remains unknown, it there- 
fore seems highly advisable to supplement splenectomy in 
this condition by the above procedures in any patient 
in whom such signs of chronic focal infection can be 
demonstrated. 



CHAPTER XIV 

TREATMENT: VALUE OF SPLENECTOMY AS A THER- 
APEUTIC PROCEDURE 

Splenectomy for rupture or severe injury of the 
spleen is one of the oldest abdominal operations about 
which we have definite knowledge. 226 It was not until the 
advent of anaesthesia and the greater surgical skill of the 
nineteenth century, however, that it was found practicable 
to remove the chronically diseased organ and thus widen 
the field of applicability of the operation beyond that of 
surgical emergencies. Unfortunately, among the chronic 
diseases of the organ first attacked were the enlargements 
incident to cirrhosis of the liver and leukaemia. The un- 
favorable results in these two diseases cast discredit upon 
the operation; but, nevertheless, in 1908, Johnston 202 was 
able to collect 708 cases of total extirpation of the spleen 
with 194 deaths. From 1900 to 1908 there were 355 cases 
with 66 deaths. If the cases of leukaemia and trauma are 
subtracted, the list is reduced to 235 cases with 27 deaths, 
or a mortality of 11.5 per cent. Since 1908 our greater 
knowledge of the physiology and pathology of the spleen 
has resulted in a better selection of cases, so that now the 
total mortality has been somewhat further reduced (Las- 
peyres, 238 Michelson, 290 Mayo 282 ). 

In the past three years a more active study of the sur- 
gical treatment of certain so-called primary anaemias has 
led to the much more general use of splenectomy, and it is 
this application of splenectomy that attracts most attention 
at present. 

299 



300 THE SPLEEN AND ANAEMIA 

Contra-indications. — It is most important to know 
when splenectomy should not be done. We now know 
that in certain diseases removal of the enlarged spleen as a 
curative measure is contra-indicated. These include the 
various forms of leukaemia, also polycythemia, and most 
cases of malaria, syphilis, and tuberculosis. In certain cases 
of cirrhosis of the liver (including the hypertrophic form) 
Eppinger has recently advocated splenectomy on account 
of the evidences of increased blood destruction in this dis- 
ease when jaundice is a prominent feature; but in the ordi- 
nary atrophic forms in the absence of jaundice the desira- 
bility of splenectomy is questionable. Too much emphasis 
cannot be laid on the necessity of ruling out atypical forms 
of leukaemia — before the splenectomy is undertaken; but, 
on account of the great variety of aleukemic conditions, 
this is often an extremely difficult task. In no case, how- 
ever, should splenectomy be advised until the blood picture 
has been carefully studied over an extended period of time 
and the presence of leukaemia excluded so far as may be 
possible. 

Anything pointing toward a hemorrhagic diathesis 
should also be given careful consideration. Its presence is, 
as a rule, sufficient to contra-indicate operation, although 
the repeated hemorrhages from varices or due to other 
mechanical causes, as in Banti's disease, are more indica- 
tions for operation than otherwise. 

In the severer anaemias definite signs of bone-marrow 
activity should also be forthcoming (nucleated or reticu- 
lated cells, Jolly bodies, etc.) . If they cannot be provoked 
by appropriate drugs or by transfusion, it is probable that 
the marrow is relatively aplastic and splenectomy should 
not usually be attempted. 



SPLENECTOMY TREATMENT 301 

That the removal of the normal spleen is followed 
by a temporary anaemia has been shown both by clinical 
observation and animal experimentation; but this should 
not be considered a contra-indication to operation. The 
apparent paradox that, while removal of the normal spleen 
causes a temporary anaemia, removal of the spleen in cer- 
tain blood diseases relieves the existing anaemia, has been 
commented upon in another section. 

Leukemia. — On account of the almost invariably fatal 
outcome of splenectomy in early cases of leukaemia, for 
some decades the operation has been considered as definitely 
contra-indicated in this condition. Occasional cases have 
been reported, however, in w r hich death did not follow sple- 
nectomy, and, in addition, the success that has attended 
this operation in recent years has inevitably tended to have 
the procedure applied to conditions which had previously 
been considered unsuitable. To help prevent the unwar- 
ranted inclusion of leukaemia in the scope of splenectomy, 
some evidence is here furnished as to the result hitherto 
obtained in this condition. In 1898, Vanverts 447 collected 
twenty-nine cases of splenectomy for leukaemia, to which 
Fevrier 113 adds two more. Of the thirty-one cases, only 
three survived the operation. Of these three cases there 
has been considerable doubt as to whether Franzolini's was 
really a case of leukaemia, and Banti did not hesitate to 
call it a case of Banti's disease. Burkhart's case was appar- 
ently operated upon in an early stage (leucocyte count 
about 43,000). That the course of the malady was not 
influenced by the operation is shown by the fact that the 
patient died eight months later with the typical physical 
signs and blood picture of leukaemia. In the third case 
(Hartmann's) improvement lasted for three years, but 



302 THE SPLEEN AND ANAEMIA 

emaciation and gingival hemorrhages then became appar- 
ent. The cause of death in almost every unsuccessful case 
is hemorrhage, whether from the pedicle of the spleen, from 
torn adhesions between the spleen and diaphragm, viscera, 
or parietal wall, or from the laparotomy wound. In the 
single case that I have had opportunity to examine, an 
aleukemic leukaemia, with a total leucocyte count ranging 
from 10,000 to 15,000, but with myeloid cells, the spleen 
was removed apparently without hemorrhage, but the ab- 
dominal wound showed no tendency to heal. Ventral hernia 
could not be avoided, and the patient died two weeks after 
operation from an acute generalized peritonitis. 

In a few cases, where the great size of the spleen or a 
complication such as extreme mobility has been the promi- 
nent symptom, splenectomy has been practised as a pallia- 
tive measure. Kuttner 233 reported one such case of the 
myelogenous type that continued to improve while under 
observation, but he recognized that the progress of the dis- 
ease had not in any way been influenced by the procedure in 
a curative sense. On account of the high postoperative mor- 
tality and of the evidence that the course of the disease is 
not affected by the operation, it is safe to say that splenec- 
tomy is definitely contra-indicated in the various forms 
of leukaemia. This is especially true in the acute form, 
while in the more chronic forms it should only be under- 
taken when the most urgent indications are present. 

Polycythemia Rubra. — On account of the fact that 
polycythemia rubra (erythremia, Vaquez's disease) is the 
only primary disorder of the red blood-cell system in which 
the cell count is increased, and that splenectomy has been 
attempted unsuccessfully in this condition, it seems advis- 
able to consider it in some detail at this point, although it 



SPLENECTOMY TREATMENT 303 

cannot, of course, be included among the anaemias. First 
described by Vaquez 44S in 1892, this peculiar syndrome 
was later brought more prominently before the medical 
profession by Osier' 524 in 1903, and its various features 
more exhaustively studied by Cominotti, 84 Hirschfeld, 178 
Senator, 405 Abeles, 2 and others. According to Luten- 
bacher, whose monograph and bibliography present the 
most complete study of this disease, the salient symptoms 
are (1) a true erythrosis of skin and mucous membrane 
(rather than cyanosis, which may also be present) , ( 2 ) dila- 
tation and engorgement of the veins of the skin and retina, 
(3) gastro-intestinal disorders, albuminuria, vertigo, head- 
ache, somnolence, and lassitude (all due to visceral ple- 
thora), (4) pains resembling erythromelalgia, (5) poly- 
globulia (up to nine or eleven million erythrocytes per 
cubic millimetre), relative increase of polymorphonuclear 
leucocytes, with attempts at medullary reaction, (6) en- 
largement of the liver and especially of the spleen, though 
these features are not a necessary part of the syndrome. 
The resistance of the erythrocytes to various hemolytic 
agents has seldom been tested in polycythemia. In most 
cases it has been found to be normal, although Guinon, 
Hist, and Simon 158 reported a case in which the resistance 
to hypotonic salt solutions was slightly increased. Pick- 
ard 354 has very recently described a case of true poly- 
cythemia in which haemolysis began at 0.48 per cent. XaCl 
and was complete at 0.30 per cent. XaCl (essentially 
normal limits ) . An increased resistance to a different kind 
of hemolytic agent, on the other hand, was shown by the 
fact that to antihuman hemolytic amboceptor the patient's 
cells showed no hemolysis when mixed with twice the 
amount of amboceptor necessary to hemolyze normal cor- 



304 THE SPLEEN AND ANEMIA 

puscles. That this is not always the case in polycythemia, 
however, is shown by the findings of Freund and Rex- 
ford, 129 in whose case the same test was performed and the 
resistance found to be normal. 

The etiology is completely unknown, though it is prob- 
able that various toxic or infectious agents may provoke 
the syndrome, either by direct marrow stimulation or 
through excessive repair after a primary red blood-cell de- 
struction. Thus Belonowsky was able to raise both haemo- 
globin and erythrocyte count by the frequently repeated 
injection of minute doses of hsemolytic serum. In true 
cases it is possible to rule out all mechanical causes, such 
as occupation, hypertension, heart and lung disease, and 
adenopathy and other alterations in the blood should not 
be present. The pathogenesis of the disease is probably 
due to a true bone-marrow hyperplasia, as is shown by the 
fact that the over-active bone-marrow is but seldom forced 
to deliver immature or nucleated red blood-cells to the cir- 
culation. All the symptoms can be explained as a result 
of this plethora. The enlarged spleen is largely spodogen- 
ous; i.e., compensatory attempt to provide for excessive 
blood destruction, with resultant increased macrophagic 
action and congestion. 

On a priori grounds, therefore, it will readily be seen 
why splenectomy should not be undertaken in this disease. 
If it is correct that the primary trouble is in the hyper- 
plastic bone-marrow, the overactive spleen should be looked 
upon as the chief agent to keep the plethora within limits 
compatible with life. A logical radical treatment would 
be the obliteration of the marrow of one or more long bones, 
or ligation of nutrient arteries, just as partial excision of 
the thyroid causes improvement in exophthalmic goitre. 



SPLENECTOMY TREATMENT 305 

Such procedure has not to my knowledge been attempted, 
and it is doubtful if a sufficient effect could be produced 
to make it of clinical value. As a matter of fact, sple- 
nectomy has been but rarely attempted, although Luten- 
bacher states that " it has been followed in several cases 
by a rapidly fatal termination from suppuration or hemor- 
rhage, and in those cases that survived it has caused an 
evident augmentation in the polyglobulia." A confirma- 
tion of the protective action of the spleen in this condition 
is afforded by the increase in polycythemia in cases where 
enlarged spleen has been reduced in size by X-ray treat- 
ment. In some cases, on the contrary (perhaps where the 
X-ray dosage to the spleen has been irritative rather than 
destructive) , this form of treatment has proved beneficial. 
Destructive X-ray applications to the long bones have not 
proved of value. Large venesections, repeated at rare 
intervals and followed by salt-solution injection, have also 
been of use in some cases, but the consequent improvement 
is always evanescent and, on the whole, this treatment must 
be considered unsatisfactory. 

Diseases in Which Splenectomy May Occasionally 

be Indicated 

Cikrhosis or the Liver. — Mention has already been 
made of the fact that Eppinger had presented an experi- 
mental basis for extending splenectomy to cases of cirrhosis 
in which j aundice was a chronic and prominent symptom. 
On account of the enlargement of the spleen that fre- 
quently is found at an early stage of cirrhosis of the liver, 
Eppinger 104 was led to search for evidences of increased 
blood destruction in this connection also. This was forth- 
coming, when jaundice was present, not only in the exist- 
20 



306 THE SPLEEN AND ANAEMIA 

ence of increased anemia, but also in the increased amount 
of urobilin found in the stool and the high iodine number 
of the blood. With less justification, but on account of 
the analogy that exists between the changes in the liver 
and spleen in portal cirrhosis and in Banti's disease, other 
authors have attempted splenectomy in portal cirrhosis 
even in the absence of jaundice or other signs of excessive 
blood destruction. Thus Jullien, 205 in 1911, reports seven 
cases treated in this way, of which two died as a result of 
the operation, while the others showed considerable im- 
provement. This even included such important changes 
as the long-continued disappearance of a chronic ascites, 
and of the superficial evidences of collateral circulation. 
Kidd 211 believes that splenectomy should be tried in all 
cases of cirrhosis showing enlargement of the spleen, and 
W. J. Mayo 281 has also found splenectomy advisable in 
cirrhosis of the liver. In addition to one case of Hanot's 
cirrhosis in which the spleen was removed with " undoubted 
benefit and possible cure," he has removed the greatly- 
enlarged spleens from four patients suffering from portal 
cirrhosis. Although it was too early to know whether or 
not the end results had justified the operation, three of 
the four patients showed marked improvement with dis- 
appearance of the ascites and anaemia. Although the evi- 
dence is still meagre on this point, and the evidence at hand 
insufficient to determine what types of cirrhosis are in- 
cluded under this term by surgeons, the results are favor- 
able enough to entitle the procedure to further considera- 
tion. In estimating their value, however, it should be 
remembered that the differential diagnosis of portal cir- 
rhosis from Hanot's cirrhosis and from Banti's disease 
and other similar conditions is often difficult or impossible 



SPLENECTOMY TREATMENT 307 

to make, and it should also be borne in mind that there is 
removed with the spleen a reservoir which to some author- 
ities is of great importance in accommodating the blood 
which accumulates behind the obstacle of the cirrhotic liver. 
Whether or not this very accumulation of blood in the 
spleen is a factor which may lead to increased blood de- 
struction is a point for the future to decide. 

Malaria and Syphilis. — The extreme size attained by 
the spleen in chronic malaria and the frequency of malaria 
in tropical regions early turned the attention of French 
and Italian surgeons toward the advisability of splenec- 
tomy in this condition. In spite of almost uniformly fatal 
results in the early cases, surgeons have persisted in their 
attempts, on account of the many distressing symptoms 
(dyspnoea, cyanosis, vomiting, dysuria, dysmenorrhoea, 
abdominal pain, etc.) that the tremendously enlarged 
spleen may cause. The operation has been, however, at- 
tended with unusual difficulties on account of the friability 
of the organ and vessels and the great number and density 
of the adhesions in most cases. This not only promotes 
the liability to severe hemorrhages, but, on account of the 
length of time required for the operation, greatly increases 
the shock of the operation. Of the twelve deaths in the 
series of forty-seven cases collected by Olgiati, 321 ten were 
due to these causes, the other two to peritonitis. Twenty 
of the thirty-five cases that recovered, on the other hand, 
had ectopic spleens, which, therefore, did not present ad- 
hesions to the surrounding organs. As it is precisely this 
type of spleen that is especially liable to the further com- 
plication of torsion of the pedicle and rupture, exploratory 
laparotomy would be indicated if the enlarged spleen had 
failed to respond to medicinal treatment and was causing 



308 THE SPLEEN AND ANEMIA 

distressing symptoms. It should, however, be recognized 
that splenectomy was undertaken for the relief of such 
symptoms and not as a curative measure. In Roumania 
splenectomy has been practised in resistant cases of 
chronic malaria with considerable improvement in many 
cases, but with the high operative mortality of over twenty 
per cent. (Racoviceanu 369 ). As all these figures, how- 
ever, date from more than fifteen years ago, the better tech- 
nique of the surgery of to-day may eliminate shock and 
hemorrhage to such a degree that the mortality in malaria 
may prove to be no higher than in the other diseases. 

In some cases of long-standing syphilis, also, when the 
enlarged spleen has proved resistant to specific treatment, 
it may be advisable to remove the organ that has become 
the chief cause of the patient's disability. Thus W. J. 
Mayo 282 has removed the greatly-enlarged spleen from 
three patients suffering from chronic syphilis and marked 
anaemia. " In one of these specific treatment had been 
carried out for two years, in another for six months, with- 
out satisfactory improvement in the general condition of 
the anaemia. Following splenectomy, there was marvellous 
improvement of the anaemia in all of them." 

The ultimate results of splenectomy in such cases will 
be awaited with great interest. It may prove that occa- 
sionally the enlarged spleen, at first protective, eventually 
assumes a pernicious activity, or that, like the central ner- 
vous system in some chronic infections, it may become a 
secluded nidus of infection which cannot be reached by 
ordinary medical treatment. In either of such contin- 
gencies its removal, therefore, may become desirable. 
Nevertheless, for the present at least, enlarged spleens 
should only be routinely removed in those cases where the 



SPLENECTOMY TREATMENT 



309 



indications have been proved to be favorable or else where 
sudden emergencies require a greater latitude in the em- 
ployment of this form of treatment. The widespread re- 
moval of spleens without accurate diagnosis or regard to 
the suitable indications will undoubtedly lead not only to 
many disastrous results but also to the indefinite obscura- 
tion of the proper field for this important operation. 

TABLE LXIV 

Collected Reports of Results of Splenectomy in Various Diseases of 

the Blood 



Disease 


Author 


Number 
of cases 


Recov- 
ered 


Died Per °?P*- 
mortality 


Gaucher's 


Erdman and Moor- 
head 106 

Krumbhaar 

Elliott and Kanavel 102 

Elliott and Kanavel 102 

Elliott and Kanavel 102 

Stillman fl7 


10 

183 

16 

23 

9 

6 
153 


8 

155 
15 

22 

9 

6 
123 


2 90 


Banti's. . 


28 
1 

1 




15 4 


Hemolytic icterus ac- 
quired 

HaemoMic icterus, con- 
genital and familial 

Haemolytic icterus, un- 
classified 

v. Jaksch's 


6.2 
4.3 





Pernicious anaemia. . . . 


Krumbhaar 


30 


19.6 



Diseases in Which Splenectomy is Indicated 

In certain types of chronic anaemia, splenectomy has 
met with considerable success; as in Banti's disease, Gau- 
cher's disease, the congenital and acquired forms of hsemo- 
lytic jaundice, and, to a lesser extent, pernicious anaemia. 
The cause of the improvement or cure that follows splenec- 
tomy in these conditions is but incompletely understood, 
and is probably different in the various diseases men- 
tioned. Some of the factors at work have been considered 
elsewhere in this book. 

Banti's Disease. — In Banti's disease it is important 
that the operation should be undertaken before the disease 



310 THE SPLEEN AND ANAEMIA 

has progressed beyond the first stage. Splenectomy in the 
first stage is not only accompanied by a lower mortality, 
but in the great majority of cases has caused great and 
lasting improvement in symptoms, often amounting to a 
complete cure. When the third stage is reached, with per- 
manent changes in the liver and circulatory system, not only 
is the operation more dangerous, but the chances of im- 
provement are greatly lessened. As a result of the disease 
process, the spleen has by this time become largely fibrotic, 
and its removal could hardly be expected to be attended 
with marked beneficial effect. 

In 1907 Torrance collected thirty-six cases of Banti's 
disease, of which nine died as a result of the operation, a 
mortality of 25 per cent. A year later Johnston added 
twenty-five cases with only three deaths, making an opera- 
tive mortality of reported cases up to 1908 of 19.7 per cent. 
By a far from exhaustive survey of the literature since 
1908 we have added 122 cases with sixteen deaths that were 
not in Torrance's or Johnston's lists, making a total of 
183 cases with twenty-eight deaths — a mortality of 15.4 
per cent. If the cases since 1910 are considered, how- 
ever, there are found 76 cases with eight deaths, a mortality 
of only 11.1 per cent. Although allowance must be made 
for the more liberal publication of favorable results, this 
last percentage is the same as that for the largest collection 
from any one clinic (Mayo) and is probably very close to 
the present operative mortality for this condition. With 
proper selection of cases and technique, Mayo believes that 
this mortality percentage can still be cut in half. On 
account of the early reporting of most cases it is impos- 
sible to get an adequate idea of the ultimate outcome of 
cases surviving operation. Occasional reports can be 



SPLENECTOMY TREATMENT 311 

found in which a marked postoperative improvement was 
followed in one or two years by subsequent relapse or 
death (Roberts, 3771 Lett, 246 Kidd, 211 Giffin 142 ). Never- 
theless, the prevalent opinion is probably correct that the 
improvement that follows splenectomy in early Banti's 
disease in the great majority of cases either amounts prac- 
tically to a complete cure or persists without relapse for 
many years. Even in the third stage, splenectomy may 
be of value: thus of the twenty cases of this series that 
were operated upon in the third stage, ascitic or cirrhotic 
stage, five succumbed to the operation and at least three 
more were not materially helped and died within a few 
years. While these figures are less encouraging than those 
for the earlier stages, they by no means should be taken as 
proof that the operation is contra-indicated in this stage. 
As early as 1906, Jaffe 197 showed that, even with marked 
ascites and advanced cirrhosis, splenectomy, if combined 
with the Talma operation, may be attended with very strik- 
ing improvement. 

A patient, then, with the symptoms of Banti's disease, 
particularly if in the early stages of the disease, should be 
considered a proper subject for splenectomy, but the most 
favorable time for operation should be selected. Before 
undertaking the operation all other possible causes for such 
a syndrome {e.g., aleuksemia, leukaemia, tuberculosis, ma- 
laria, syphilis, etc.) should be ruled out so far as possible 
by a complete but not unnecessarily prolonged investiga- 
tion as to the cause of the disease, through frequently re- 
peated blood examination. In the third or ascitic stage a 
combination of splenectomy with the Talma operation is 
advisable. 

Gaucher's Disease. — On account of the raritv of this 



312 THE SPLEEN AND ANAEMIA 

condition and the difficulty of diagnosis without the aid of 
histological examination, not many cases are available for 
study. In 1914, Erdmann and Moorhead 106 collected ten 
cases of large-celled splenomegaly (Gaucher's disease) in 
which the spleen had been removed, and of these, two died, 
both within twenty-four hours of operation. While this 
probably represents too high a mortality, the improvement 
which followed in the other eight cases cannot always be 
taken as indicative of eventual cure, for the disease is 
known to exist independently in the bone-marrow and 
lymph-nodes. It would therefore seem wiser to restrict 
splenectomy in this disease to those cases that are unusually 
handicapped by the results of the disease, but are still good 
surgical risks, and in such cases to limit the prognosis to 
improvement and not to promise complete cure. 

Hemolytic Jaundice. — The field in which splenec- 
tomy has been practised with the greatest success is un- 
doubtedly that of hsemolytie jaundice. Both in the ac- 
quired form (Hayem-Widal) and the congenital or fa- 
milial type ( Chauffard-Minkowski) , marked improvement 
and frequently complete cure have resulted from removal 
of the spleen. In fact, the success obtained in this type of 
case, where the chief vitium is that of increased blood de- 
struction, has been a powerful incentive toward extending 
the operation of splenectomy to the wider range of allied 
diseases discussed in this chapter. Splenectomy was first 
tried in this condition by Vaquez and Giroux. As their 
case, however, died two days after operation, Chauffard's 
dictum that hsemolytie jaundice constituted a "Noli me 
tangere " for the surgeon prevailed for several years. In 
1911, however, splenectomy was again tried in hsemolytie 



SPLENECTOMY TREATMENT 313 

jaundice with a very different result from that in Vaquez 
and Giroux's case. In that year Micheli removed the 
spleen from a case of the acquired type with the most strik- 
ing improvement : the blood count, which had been between 
980,000 and 2,600,000, quickly rose to almost normal, the 
acholuric jaundice and urobilinuria disappeared, the fra- 
gility of the red cells was lessened, and the patient within 
a few months was apparently cured. Similar beneficial 
results were obtained by Banti in his two cases of hemolytic 
splenomegaly, which we have taken to be identical with the 
acquired form of hemolytic jaundice. Success was ob- 
tained in other early operations (Kahn, Roth), and the 
procedure would undoubtedly have been in more frequent 
and intelligent use, in this country as well as Europe, if 
the unfortunate grouping of several clinical entities under 
the cloak of " Splenic anaemia " had not clouded the worth 
of the procedure. In 1915, Elliott and Kanavel 102 were 
able to collect forty-eight cases of hemolytic j aundice ( six- 
teen acquired, twenty- three familial, and nine unclassified) 
that had been treated in this way. Of the forty-eight cases, 
only two died — one shortly after operation, the other from 
sepsis, six weeks after operation. The other forty-six are 
reported as " cured," this result being based upon the 
disappearance of jaundice and exacerbations, and decrease 
of the ansemia and the urobilin excretion. The effect on 
the resistance of the red cells was not constant; in some 
instances the resistance returned almost to normal, but in 
most cases the red cells remained almost as fragile as before 
operation. In spite of these brilliant results, however, it 
must be remembered that the primary cause of the disease 
is unknown and is probably not in the spleen. The case 



314 THE SPLEEN AND ANAEMIA 

reported by Whipham 467 emphasizes this point; although 
splenectomy was followed by great clinical improvement, 
return of the red blood-cell count to a level above normal 
(polyglobulia) and a reduction of their fragility to a nor- 
mal level, nevertheless, three months after operation, 
jaundice and extreme anaemia returned and the child died 
in a " crisis of deglobulization." " Whatever the causa 
causorum, it must be regarded as established that it is 
through the instrumentality of the spleen that pathologic 
haemolysis is wrought." 

v. Jaksch's Disease. — The results of splenectomy in 
v. Jaksch's disease are too meagre to be of value. Only 
six cases have so far been reported (Stillmann 417a ), and, 
although all of these were improved by the operation, it 
must be admitted that paediatrists claim even greater im- 
provement or even cure after long-continued medical treat- 
ment of this condition. It should be noted that the first 
case reported by Stillmann exhibits certain features more 
compatible with the diagnosis of haemolytie jaundice than 
•of v. Jaksch's disease (decreased resistance of erythrocytes, 
great increase in reticulated erythrocytes, and a practically 
normal leucocyte count) . 

Pernicious Anaemia. — The most important disease, 
from the point of view of its greater frequency and greater 
severity, to which splenectomy has been applied is per- 
nicious anaemia. The striking improvement that has been 
shown to follow removal of the spleen in such diseases as 
haemolytie jaundice and Banti's disease naturally led to 
an extension of this clinical procedure to allied conditions. 
In 1913 three investigators — Eppinger, 104 Decastello, 92 
and Klemperer, 216 — working independently, tried splenec- 
tomy as a therapeutic measure in pernicious anaemia. It 



SPLENECTOMY TREATMENT 315 

is interesting that Eppinger was led to adopt this pro- 
cedure by observing after splenectomy a diminished output 
of urobilin and other evidences of decreased haemolysis. 
Decastello, on the other hand, had noted the improvement 
that followed splenectomy in the related conditions, haemo- 
lytic jaundice and Banti's disease; whereas Klemperer was 
influenced by the clinical observation that splenectomy for 
such conditions as rupture of the spleen was in some in- 
stances eventually followed by polycythemia. 

Such marked improvement was noted in these earlier 
cases that the procedure was quickly and widely repeated, 
chiefly in Germany and in this country, so that a fairly 
large group has already become available for study. More 
prolonged observation, however, has shown a considerable 
mortality from the operation and postoperative complica- 
tions, and, moreover, that very few of the patients con- 
tinue steadily to improve; in almost all the characteristic 
blood picture of pernicious anaemia remained, and not a 
few died from relapses of the disease in the first year or two 
after operation. The object of this section is to show by 
a correlation of the published reports, with later informa- 
tion obtained by personal communication, just how valu- 
able splenectomy has thus far proved to be in pernicious 
anaemia. 230a 

Although it has been impossible to get additional re- 
ports from some of the German authors, and of some 
patients who have been lost sight of, nevertheless the re- 
sults obtained in the last two and one-half years are suffi- 
ciently concordant to give evidence of some value. In 
drawing conclusions from any such review, however, it must 
be remembered that certain difficulties are unavoidable. 
For instance, the dividing line between pernicious anaemia 



316 THE SPLEEN AND ANEMIA 

and some of the other primary blood diseases is necessarily 
such a shadowy one that the possibility of an incorrect 
diagnosis must always be borne in mind. Then, too, the 
concept of pernicious anaemia varies so much with different 
authorities that cases included as such by one author might 
easily be rejected by another. Thus one of the earlier 
cases of splenectomy that was followed by marked and 
long-continued improvement, when subjected to critical 
analysis, seems to be rather a case of acquired hemolytic 
jaundice than of true pernicious anaemia. In another case 
reported as pernicious anaemia the diagnosis was later 
changed to haemolytic jaundice on account of the subse- 
quent appearance of acholuric jaundice with diminished 
resistance of the erythrocytes. As such variations in 
diagnosis are apt to include less serious diseases under the 
head of " pernicious anaemia," or diseases in which sple- 
nectomy is already known to be of benefit, the present sta- 
tistics will be correspondingly favored by such inclusions. 
In applying the present figures to prognosis, however, it 
is fair to offset the inclusion of such cases with the results 
that must inevitably follow the better selection of cases 
and better preparation for operation. A third considera- 
tion is that the term " pernicious anaemia " may later be 
found to include more than one clinical entity. ( Compare 
the great variations that occur in the size of the spleen, 
in the bone-marrow reactions, in the evidences of haemol- 
ysis, and in the duration of the disease.) If this were 
found to be true, it might well be that some of the appar- 
ently discordant results that have been observed after sple- 
nectomy are due to the fact that the operation was of 
value in one or more types and contra-indicated in the 
others. The results of these studies are included in 
Table LXV. 



SPLENECTOMY TREATMENT 



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318 THE SPLEEN AND ANAEMIA 

Analysis of Results. — It will be seen that of the 153 
individuals whose spleens were removed, thirty died within 
six weeks, presumably from the effects of the operation, a 
mortality of 19.6 per cent. Of the remaining 123 patients, 
all but twenty-four showed a distinct improvement, both 
in general condition and in blood picture. Of the twenty- 
four individuals that survived the operation but failed to 
improve, a few were obviously harmed by it. To this 
group belongs Pappenheim's case, splenectomized at a 
favorable time, when the patient was in the stage of a re- 
mission. The condition, nevertheless, was aggravated by 
the operation : the blood showed signs of increased destruc- 
tion and a serious relapse began. The improvement noted 
in the majority of cases lasted varying periods. Thus at 
the end of six months, of fifty-three patients who had sur- 
vived operation for more than six weeks and were still 
under observation, forty-four had still continued to im- 
prove and none had died, but nine had already relapsed. 

TABLE LXVI 

Late Results After Splenectomy in Pernicious Anaemia 



Number cases known. 

Still improved 

Relapsed 

Died subsequently. . . 



After one 


After two 


year 


years 


27 


6 


11 


3 


7 


2 


9 


1 



At the end of the first year after operation there re- 
mained twenty-seven patients who were still under ob- 
servation ( see Table LXVI ) . Of these, Decastello's series 
is the most important, not only because he and Eppinger 
were the first to try this procedure and therefore the cases 
could be followed for a longer time, but because the early 



SPLENECTOMY TREATMENT 319 

successful results have been greatly modified by time. Of 
six patients at the time of his publication, several months 
after operation, four showed such great improvement that, 
except for the microscopic appearance of the blood, they 
might have almost been considered cured. Two years later, 
however, two were dead and one was in as poor condition 
as before operation. Of the other two important early 
series, Eppinger's and Klemperer's, it has been impos- 
sible to get additional information. The figures for the 
whole group of twenty-seven cases, however, show that the 
initial improvement has been maintained in less than half 
of the cases. 

A small but interesting group is formed by six indi- 
viduals ( see Table LX VI ) that have been known to have 
lived two years or more after operation (Descatello [two], 
Gifrin, Harpole, Huber, Thayer). Of these, Giffih's 
patient had had the disease for two and one-half years; 
the anaemia was not extreme at the time of the operation, 
and the spleen was much enlarged ( 1640 gm. ) . Improved 
by the operation, he died three years later from pneumonia. 
In Decastello's two cases the disease had existed for less 
than a year; the anaemia was severe and the spleen but 
slightly increased in size. These patients improved after 
operation both clinically and as to the blood picture; but, 
whereas one in a subsequent report was in poor condition, 
the other was without symptoms, although the blood picture 
was still that of pernicious anaemia. Harpole's patient was 
known to have had pernicious anaemia for two years, and 
at the time of operation the anaemia was moderately severe 
and the spleen twice the normal size. After splenectomy 
there occurred immediately an active bone-marrow re- 
action with marked clinical improvement. The patient has 



320 THE SPLEEN AND ANAEMIA 

continued in fair health, with only a slight anaemia, but 
with persistence of spinal-cord symptoms. Huber's 
patient, who was considered moribund at the time of opera- 
tion, improved rapidly for seven weeks, relapsed, and later 
underwent a spontaneous remission. After two and one- 
half years she was still in good condition and able to do her 
housework, but still anaemic. Thayer's patient, having 
had the disease one year, improved after splenectomy, 
although there was no bone-marrow reaction. After eight- 
een months the patient relapsed to the same condition 
as before operation and was last reported in poor condition. 
Estimation of the value of such a procedure as splenec- 
tomy in pernicious anaemia must take into consideration 
not only the actual results obtained, but a comparison, so 
far as is possible, with the probable results if operation 
had not been undertaken. Thus, whereas we have seen 
that splenectomy caused a quick and marked improvement 
in 64 per cent, of all patients, natural remissions occurred 
at one time or .another in over 80 per cent, of the patients 
of Cabot's 65 series treated by the older conservative meth- 
ods. One cannot maintain from* this that perhaps the im- 
provement after splenectomy was only a coincidental re- 
mission, because the onset of improvement was too closely 
and constantly related to the postoperative period; but it 
does offer some basis for the contention that other methods 
of treatment may yield results as striking as those fol- 
lowing splenectomy. However, from the aspect of dura- 
tion of the disease the evidence is more in favor of the sple- 
nectomized series. In Cabot's series, almost half died in the 
first year of the disease, and of the remainder, one-third died 
in the next year (compare Table LXVII) . As the dura- 
tion of the disease in the splenectomized series had already 



SPLENECTOMY TREATMENT 



321 



averaged one and one-half years before operation, they 
should be more properly compared with the remainder of 
Cabot's group. By the end of the first year conditions 
in the splenectomized group were as follows: Of thirty- 
three patients surviving the operation, twenty-four were 
still improved, three had failed to show improvement or 
had relapsed to their pre-operative condition, and six had 
died. If postoperative deaths, however, are included, only 
about half of those whose fate was known were still alive 
at the end of the first year. From both these points of 
view, therefore, there are no clear indications as to the value 
of splenectomy. 

TABLE LXVII 

Results According to Duration of Disease, Based on Ninety-Five Case* 



Duration 



Number 
of 

cases 



Postoperative results 



Deaths 



Not im- 
proved 



Improved 



Subse- 
quently 
died 



Under 6 months .... 
Six months to 1 year 

One to 2 years 

Over 2 years 



17 
26 
36 
16 



13 

19 

27 

9 



The changes in the blood picture after splenectomy are 
striking and fairly constant. Forty-seven cases are stated 
to have had a distinct postoperative blood crisis (appear- 
ance of normoblasts, megaloblasts, reticulated erythrocytes, 
Jolly bodies, etc., in larger quantities) ; and, as statements 
that the blood crisis failed to appear are very rare, it is 
fair to assume that such a phenomenon is at least a fre- 
quent occurrence. In most of the patients who recovered 
the stimulation forms soon grew fewer in number and, 
coincident wtith the) signs of general improvement, the 
haemoglobin and red-cell count rose. The color-index, how- 

21 



322 THE SPLEEN AND ANEMIA 

ever, usually remained high. As might be expected, also, 
the nucleated forms became fewer or disappeared ; and yet 
statements are almost unanimous that the microscopic 
features of the blood (tendency to macrocytosis, poikilocy- 
tosis, etc.), even in many cases that showed almost normal 
counts, remained suggestive of pernicious anaemia. Those 
patients who died within the first six weeks after operation 
showed either very slight improvement in the blood picture 
or an actual deterioration ; whereas, death occurring after 
that period was in many cases preceded by a distinct im- 
provement in the blood picture, with the usual signs of a 
remission. 

Those few patients who up to the present time have 
continued well after operation must also be taken into con- 
sideration. By the older methods of treatment, Cabot, in 
the first edition of " Modern Medicine," stated that six out 
of 1200 cases after six years of health might be said to 
have been cured. In the second edition this number was 
reduced to three. May it not develop that a larger per- 
centage of such " cures " will follow splenectomy, even 
though the blood picture does not return absolutely to 
normal? Another point brought out by study of the blood 
picture at the time of operation is that if the operation is 
undertaken before the blood has reached an extreme degree 
of deterioration, not only is the operative risk lessened, 
but the improvement is greater and more lasting. In any 
case it is wise to precede it with one or more transfusions. 

The average age of the patients at the time of operation 
(see Table LXVIII) was forty-five; the average duration 
of the disease at that time, 1.6 years. If the results are 
analyzed in groups subdivided according to age, it appears 
(as one would expect) that less favorable results are ob- 



SPLENECTOMY TREATMENT 



323 



tained in patients in the sixth and seventh decades. A 
similar arrangement on the basis of duration of the disease 
shows that the best results are obtained ( after the operation 
has been successfully passed) in those patients who have 

TABLE LXVIII 

Results According to Age op Patient, Based on One Hundred and 

Twenty-One Cases 



Age, 


Number 
cases 


Postoperative results 


Subse- 
quently 
died 


decade 


Deaths 


Not improved 


Improved 


3d 

4th 


8 
23 
43 

28 
9 


2 
4 
5 
4 
5 


1 
2 
2 
5 
2 


5 
17 
36 
19 

2 


1 

2 


5th 


8 


6th 


6 


7th 


1 







had the disease for less than one year. Sex has not been 
found to exert any influence on the results. 

When arranged according to the degree of anaemia at 
the time of operation, one fact is patent : that the operative 
risk is much greater in those cases in which haemoglobin 
is below 20 (see Table LXIX). This is, of course, for 

TABLE LXIX 

Results According to Preoperative Degree of Anemia, Based on One 
Hundred and Fourteen Cases 





Number 
of 

cases 


Postoperative results 




Haemoglobin 


Deaths 


Not im- 
proved 


Improved 


quently 
died 


Below 20 


9 
29 
33 
43 


7 
6 

2 

7 


1 

2 
2 

7 


1 

21 

29 
29 




Below 30 


3 


Below 40 


7 


Above 40 


5 







this disease, a lower level even than that of 1,000,000 
erythrocytes. 

Except for this point, on account of the great fluctua- 
tions in blood counts incident to the disease and following 



324 



THE SPLEEN AND ANAEMIA 



transfusions, it is difficult to estimate whether or not the 
previous condition of the blood has any marked influence 
on the result obtained. The impression is gained, however, 
that the best results follow splenectomy in those cases that 
are not extremely anaemic at the time of operation and that 
have shown considerable fluctuations in the blood picture. 

Information as to the size of the spleen was secured in 
eighty-nine cases (see Table LXX). In twenty-eight 
cases (31 per cent.) the spleen was either small or approxi- 

TABLE LXX 

Results According to Size of Spleen, Based on Eighty^nine Cases 





Number 

of 

cases 


Postoperative results 




Size of spleen 


Deaths 


Not im- 
proved 


Improved 


quently 
died 


Normal or diminished 

Slightly enlarged 


28 
41 
20 


9 
1 


5 
4 
1 


14 
32 

18 


2 
9 


Considerably enlarged 


3 



mately normal in size. In forty-one cases (46 per cent.) 
the spleen was slightly enlarged (between 250 and 500 
gm. ) ; and in twenty cases ( 23 per cent. ) it was consider- 
ably enlarged. In other words, although seldom palpable 
before operation, it was distinctly enlarged in over two- 
thirds of the cases. If the results of splenectomy are 
subdivided according to the size of the spleen, it will be 
seen that better postoperative results were obtained in 
the cases with enlarged spleens. The third group in this 
arrangement, however, is the only one that could be said 
to have fared better than another as regards the ultimate 
outcome of the disease. 

The Effect Produced by Splenectomy. — Whatever 
the cause of the distinct improvement after splenectomy 
in those patients who survive the operation, it is obvious 



SPLENECTOMY TREATMENT 325 

that it is not due to the removal of the sole cause of the 
disease. If Eppinger's theory of thickened arteriole walls 
in the spleen, with consequent damming back and destruc- 
tion of red cells in the splenic pulp, were correct, removal 
of the spleen should indeed cure the disease ; hut our studies 
show that this is not the case. On Eppinger's theory, also, 
the characteristic remissions of pernicious anaemia would 
be difficult to explain. 

The postoperative blood crisis discussed above, and the 
subsequent improvement in the blood picture, decrease in 
urobilin, etc., indicate both that a stimulus has been applied 
to the bone-marrow and that a source of blood destruction 
has been removed. Lee's findings of an increased number 
of platelets after splenectomy would also support the bone- 
marrow stimulation theory. Hypotheses to explain these 
phenomena have been unsatisfactory and the relevant ex- 
perimental evidence often contradictory. Klemperer be- 
lieves that the bone-marrow activity is induced by removal 
with the spleen of an inhibiting hormone, but from ex- 
periments in our laboratory we have found 340 (in normal 
animals, to be sure ) not only that this bone-marrow activity 
does not occur until after several months have elapsed, but 
also that fresh splenic extract stimulates 228 instead of in- 
hibiting the bone-marrow. The cause for the blood crisis, 
therefore, must probably be sought elsewhere : perhaps, as 
has been suggested, in bone-marrow stimulation from 
metabolic products or from abnormal constituents of the 
erythrocytes that are allowed to remain in the blood by 
the removal of the spleen (Decastello) . It is also difficult 
to prove that the lessened haemolysis after splenectomy, as 
shown by decreased output of urobilin, is actually due to 



^^m 



326 THE SPLEEN AND ANAEMIA 

the absence of the spleen. Neither normal spleens nor 
those removed at operation in cases of blood disease (Cole- 
man, Stewart, Robertson) can be shown to possess demon- 
strable hemolytic activity, and studies of the blood enter- 
ing and leaving the spleen have also failed to throw light 
on the supposed hemolytic function of this organ ( Krumb- 
haar and Musser 228 ) . 

Another factor to be considered is changes in the red 
blood-cells themselves. In one case that I had an oppor- 
tunity to study (Stewart's), the resistance of the erythro- 
cytes was distinctly increased after splenectomy, so that 
this might constitute one of the factors of improvement 
after operation. A similar increase in the resistance of 
the erythrocytes we have found to be the rule 209 after the 
removal of the spleen in normal animals, and it is present 
in other blood diseases, but has been denied in some cases 
of pernicious anaemia (Moffitt) . 

Whatever the cause of the improvement, it is highly 
probable that the subsequent deterioration is due to other 
related structures taking over the functions of the spleen 
(haemolymph-nodes, accessory spleens, Kupffer cells in the 
liver, and perhaps ordinary lymph-nodes), although here, 
also, no positive evidence has as yet been produced. Assum- 
ing that the cause of the disease has not been removed, 
the logical sequence would be that when these auxiliary 
organs have sufficiently developed the interrupted course 
of the disease would be resumed. 

As to the few patients who up to the present time have 
continued well after operation, if the curative action of 
splenectomy is denied, one must assume either that the 
causative factor has for reasons unknown ceased to operate, 



SPLENECTOMY TREATMENT 327 

or that the auxiliary organs have failed to develop into 
pernicious activity. 

Indications for Splenectomy in Pernicious Ane- 
mia. — In what types of pernicious anaemia, then, should 
splenectomy be undertaken? One of two lines may be 
followed, and it is as yet too early to say which, if either, 
is correct. If splenectomy merely induces a remission — 
and this is at present the opinion of the majority of ob- 
servers — it should be logical to undertake it only as a last 
resort, when all other measures have proved unavailing, 
and only with the hope of prolonging life. Even under 
such limitations, however, the procedure has already proved 
its value, and in several cases moribund patients have been 
brought back to life of comparative well-being for many 
months. Assuming, on the other hand, that an occasional 
patient may be, for practical purposes, cured of the disease, 
and giving due weight to the view that greater and longer 
continued improvement is obtained if the operation is per- 
formed before the disease has reached its final stage, it 
would then be advisable to undertake it as soon as possible. 
Another factor that may prove to be decisive is whether 
or not increased haemolysis can be proved. In those cases 
with clinically enlarged spleens, icteroid appearance, and 
increased urobilin output, without increased resistance of 
the erythrocytes, the prognosis is distinctly more favorable 
than in the opposite types. The condition of the bone- 
marrow is also important, splenectomy being contra-indi- 
cated if the bone-marrow is persistently aplastic. It has 
also been a matter of clinical observation that those indi- 
viduals in whom spinal-cord symptoms have already de- 
veloped are less apt to be helped by the operation. 



328 THE SPLEEN AND ANAEMIA 

Summary or Results of Splenectomy in Pernicious 

Anaemia 

1. Of the 153 patients studied, 19.6 per cent, died 
within six weeks; a distinct improvement in the clinical 
condition and in the blood picture occurred in 64.7 per 
cent., and no improvement in 15.7 per cent. 

2. The rather high postoperative mortality (practically 
20 per cent.) may be due to poor choice of cases in the 
early series. As a much greater proportion of the more 
recent cases has survived the operation, the true postopera- 
tive mortality is probably much less than 20 per cent. 

3. Of the individuals who showed improvement shortly 
after operation — nearly two-thirds of the total number — 
a large number have failed to maintain this improvement, 
or have since died in a relapse or from intercurrent disease. 

4. Although a few have continued in good condition 
during the period of observation (over two years), in no 
case can it be said that a cure has been effected, and the 
blood of these individuals continues to show many of the 
characteristic signs of pernicious anaemia. 

5. On account of the improvement that follows splenec- 
tomy, it would appear to be not only a justifiable, but in 
many cases an advisable, procedure ; but in no case should 
a cure be promised or the operation undertaken except 
under the most favorable conditions. 

6. The best results are obtained if the operation is pre- 
ceded by one or more transfusions, and those patients who 
relapse after operation may still be greatly helped by trans- 
fusion. Whether or not transfusions would have produced 
equally good results in the absence of splenectomy is a 
question that cannot at present be decided. 

7. The most favorable results may be expected in indi- 



SPLENECTOMY TREATMENT 329 

riduals who have not passed the fifth decade, in whom the 
disease has not progressed for more than a year, and who 
have a relatively good blood picture (that is, an amrmia 
that is not of too extreme a degree or of the steady, pro- 
gressive type). Individuals with enlarged spleens have 
done better than those in whom the spleen was small or of 
normal size, as have also those suffering from an ansemia 
characterized by excessive hsemolysis. 

8. The opposite of these conditions should be considered 
as unfavorable factors, as should also the existence of 
spinal-cord symptoms or the presence of an aplastic bone- 
marrow. 

Choice of Time for Operation. — On general prin- 
ciples it may be said that splenectomy should be under- 
taken as soon as the diagnosis is definitely settled. In 
certain instances, however, exceptions must be made. A 
"crisis of deglobulization " in hsemolytic jaundice or a 
severe hemorrhage from a mucous membrane in Banti's 
disease would indicate postponement of the operation until 
the conditions are more favorable. The existence of a pos- 
sible contributing factor, as indicated, for example, by the 
finding of a positive Wassermann reaction or of malarial 
organisms, would naturally postpone operation until the 
influence of such factors had been, so far as possible, elimi- 
nated. When the ansemia is severe — and this applies par- 
ticularly to pernicious ansemia — a series of blood trans- 
fusions (often four or more) should precede operation. 
If the patient's blood in this way is temporarily enriched, 
not only is the operative risk lessened, but more lasting 
benefit ensues. Good results have been obtained in per- 
nicious ansemia by the subcutaneous or intraperitoneal 
injection of splenic extract, 187 and in cases where the so- 



330 THE SPLEEN AND ANAEMIA 

called " blood crisis " fails to materialize after splenectomy, 
indicating a failure of the bone-marrow to respond, this 
procedure might be tried. 

It may be said, in summarizing, that splenectomy has 
already proved its worth in many clinical conditions. Even 
in those conditions in which the early enlargement of the 
spleen is apparently of a protective nature, evidence exists 
to show that after a certain stage its hyperplasia results 
in an increased functioning that is more harmful to the 
organism than otherwise. When this stage is reached, re- 
moval of the spleen usually effects at least a temporary 
improvement in the patient's condition* Splenectomy 
should certainly be given careful consideration in all the 
diseases characterized by evidences of increased blood de- 
struction, and the fact must be emphasized that in early 
Banti's disease and the hasmolytic jaundices the results 
have been excellent and in many cases have practically 
amounted to a cure. Such an operation, however, should 
be regarded conservatively, so long as so much of the physi- 
ology of the spleen remains unknown. 



PART III 

SURGICAL OBSERVATIONS 
BY CHARLES H. FRAZIER 



CHAPTER XV 

THE SURGICAL TREATMENT OF LESIONS OF THE 
SPLEEN 

In the first century Pliny made the observation, of 
merely historical interest to us, that sometimes the spleen 
is a peculiar hindrance to runners, so that it is burned away 
from those who are incommoded by it ; also it has been said 
that the Romans removed the spleen from some of their 
gladiators to give them greater endurance in contests. It 
is, however, a far cry from that day to the nineteenth cen- 
tury, and it was only toward 1860, in the latter part of this 
century, that splenectomy was admitted to the roll of ac- 
cepted and approved surgical procedures, while the most 
important contributions to the surgery of the spleen have 
been offered during the past five years.. 

The lesions for the treatment of which the surgeon 
is called upon to operate are varied and numerous. Be- 
ginning with injuries, such as wounds and rupture, there 
were added wandering spleen, malarial spleen, abscess of 
the spleen, Banti's disease, the two types of hemolytic 
icterus, and, finally, pernicious anaemia. 

Gunshot and Stab Wounds. — The spleen enjoys a 
measure of protection from its position beneath the left 
costal arch, but occasionally it is injured by bullet and stab 
wounds. As with all injuries to the spleen, hemorrhage 
is at once profuse and alarming and, unless surgical relief 
is immediately available, the patient dies of shock or col- 
lapse. Should the splenic artery itself or the vein be punc- 
tured with or without penetration of the spleen, hemor- 

333 



334 



THE SPLEEN AND ANAEMIA 



rhage will be so profuse that the life is lost before surgical 
treatment can be applied. The diagnosis can be only 
conjectural, but suspicion should be aroused by the con- 
stitutional signs of profuse hemorrhage, with perhaps dul- 

TABLE LXXI 
Results op the Treatment of 52 Cases of Stab Wound by Various Methods 



Operation 


Total 
cases 


Recovered 


Died 


Splenectomy 


14 

24 

12 

2 


9 
22 
10 

1 


5 
2 
2 
1 


Suture 


Tamponage 


Treatment not specified . 
Totals 


52 


42 


10 

19.49 

per cent. 





TABLE LXXII 

Results of the Treatment of 82 Cases of Gunshot Wound by Various 

Methods 



Operation 


Total 
cases 


Recovered 


Died 


Splenectomy 

Tamponage 


40 

18 
9 
1 
1 
6 

1 

6 


25 

10 

5 

1 

1 


15 

8 
4 

1 
5 

1 

6 


Suture 


Partial excision 


Cauterization 


Treatment not specified . 
Death previous to opera- 
tion 


Wounds not detected at 
the operation 

Totals 


82 


42 


40 

48.2 

per cent. | 





ness on percussion in the left flank or when the site or direc- 
tion of the wound points to the spleen. Immediate opera- 
tion is imperative, and the treatment of the injured organ 
will depend somewhat upon the extent and character of 
the wound. Bullet and stab wounds may be effectively 
dealt with by suture, but when there is more or less ex- 



SURGICAL TREATMENT OF LESIONS 335 

tensive laceration, when hemorrhage cannot he otherwise 
controlled, or when the vessels of the pedicle are involved, 
splenectomy is clearly indicated. In superficial wounds 
the insertion of a free epiploon has been used advantage- 
ously for the control of hemorrhage. Of ninety-nine cases 
of w r ounds of the spleen, 50 per cent, of the sixty-one cases 
of gunshot wounds and 80 per cent, of the thirty-eight 
stab wounds recovered (Finkelstein 11G ). 

Rupture of the Spleen. — Rupture may be designated 
as traumatic or spontaneous — the former the result of 
trauma upon a healthy organ, the latter implying an organ 
already the seat of a pathologic lesion, often of an inflam- 
matory nature, be it malarial, typhoidal, or tuberculous. 
Rupture of the spleen follows accidents not unlike those 
which would cause a rupture of the kidney, but in the ma- 
jority of instances the kidney will rupture and the spleen 
escape. The passage over the body of wagon w r heels, 
crushes beneath heavy objects, automobile and railroad 
accidents, the kick of horse or man, falling upon angular 
objects, or falls from a distance may be numbered among 
the possible causes, and together with the ruptured spleen 
one often finds fracture of one or more ribs. 

As with gunshot or stab wounds, rupture of the spleen 
can be surmised only by the character of the injury, by the 
evidence of an overwhelming hemorrhage with signs of 
profound shock or collapse, by the presence of dulness in 
the flank, accompanied in the occasional case by fracture 
of the ribs in the left side. While there are instances of 
spontaneous recovery, the majority of cases of rupture of 
the spleen would be rapidly fatal without surgical inter- 
ference. Immediate operation should be the rule whenever 
rupture of the spleen is suspected, and the measure to be 
adopted will depend upon the extent and depth of the 



336 



THE SPLEEN AND ANEMIA 



wound. If the latter be superficial, hasmostasis may be 
effected by simple suture or, as Kirschner 214 suggested, 
by the envelopment of the organ with fascia. At all events, 
one should give preference to conservative practice, if not 
thereby adding to the risk of operation. There may be 
many instances, particularly after massive hemorrhages, 
when the more radical operation, splenectomy, may be done 
more expeditiously than one or the other of the conserva- 
tive methods and should therefore be the method of choice. 

Mortality of Rupture of the Spleen 
table lxxiii 

I. Michelsson 



Operation 


Cases 


Recovered 


Died 


Splenectomy. ......:... 


254 
24 
10 
10 


166 
19 

8 
6 


88 
5 
2 
4 


Tamponage 


Suture 


Other methods 


Totals 


298 


199 


99 

33.2 

per cent. 



TABLE LXXIV 
II. Literature op the Last Five Years 



Operation 


Cases 


Recovered 


Died 


Splenectomy 


68 
11 

4 


55 

8 
4 


13 
3 


Tamponage 


Suture 


Totals 


83 


67 


16 
19.3 

per cent. 



Of 298 cases in Michelsson's 290 collection, treated in 
various ways ( Table LXXIII ) , the mortality was 33.2 per 
cent., while, excluding all but those operated upon from 
1910 to 1915, the mortality has fallen to 19.3 per cent., or 
almost one-half (Table LXXIV.) 



SURGICAL TREATMENT OF LESIONS 337 

The prognosis of spontaneous rupture of the spleen is 
influenced by the nature of the pathologic process. If, 
prior to the rupture, the patient's condition have been de- 
preciated by a more or less virulent and prolonged infec- 
tion, as of malaria or typhoid fever, the likelihood of sur- 
vival after an overwhelming hemorrhage is naturally less 
than when rupture occurs in an otherwise healthy subject 
or organ. 

Abscess. — Because of its vascularity and the slowness 
of its blood cm-rent the spleen is frequently the site of infec- 
tion, either by the microorganisms themselves or by infec- 
tious emboli. Thus we have the secondary infection of the 
spleen in the acute fevers, such as typhoid and typhus, or in 
septicaemia, and the primary involvement of malaria, tuber- 
culosis, syphilis, and echinococcus disease. An abscess of the 
spleen may develop secondarily to any focus of infection 
and occasionally may result from a contiguous infection, 
as from perforation of the stomach or subphrenic abscess. 
Because of the greater frequency of malaria, dysentery, 
and typhoid fever, in tropical countries, and of the peculiar 
susceptibility of the spleen to these infections; abscess of 
the spleen is of greater incidence in the warm and tropical 
climates than in the temperate zone. 

The diagnosis of splenic abscess is frequently not made 
until the infection has extended beyond the capsular limits. 
A palpable spleen or one enlarged and tender may be of 
little significance and the symptoms may vary according 
to whether the abscess be located in the upper or lower pole. 
If in the lower pole, an enlarged and painful swelling may 
be felt; if in the upper pole, the most suggestive signs are 
those of diaphragmatic invasion or diaphragmatic pleurisy. 
While there may be theoretical objections to exploratory 

22 






338 THE SPLEEN AND ANEMIA 

aspiration, it seems to have been practiced frequently with- 
out untoward effects and must be recognized as the most 
reliable of all the diagnostic guides. The diagnosis once 
established, recourse should be had to surgical intervention, 
since spontaneous rupture of the abscess usually terminates 
fatally. 

The surgical treatment of abscess of the spleen may 
imply either a splenotomy or a splenectomy. While the 
choice of operation must be left to the judgment of the 
operator, generally speaking the safer operation of the two 
is splenotomy, and this is especially the case if the spleen 
be surrounded with adhesions. Splenectomy should be re- 
served for those exceptional cases where the spleen is free 
from adhesions and can be removed without the dangers 
of contamination of the peritoneum. The approach to the 
abscess in splenotomy may be transpleural, abdominal, or 
retroperitoneal. The transpleural route is peculiarly 
adapted to upper-pole involvement, especially when the 
pole is surrounded by adhesions or the infection has ex- 
tended to the subdiaphragmatic space or the pleural cavity. 
The problem thus becomes similar to that of dealing with a 
left-sided sub- or epi-diaphragmatic abscess. If the visceral 
or parietal pleura be not adherent, the operation is divided 
into two stages, being content at the first with suture of the 
parietal pleura to the diaphragm. Otherwise, after resec- 
tion of a portion of the ninth, tenth, or eleventh rib in the 
post-axillary line, the operator proceeds at once to open the 
abscess through the diaphragm. 

To expose and drain an abscess in its lower pole or, 
if need be, to remove the spleen, ready access is obtained 
by the abdominal route. The incision runs parallel with 
the last rib, and the latter should be resected, if necessarv 



SURGICAL TREATMENT OF LESIONS 330 

to establish direct drainage. During the exploratory steps 
and during evacuation of the abscess the peritoneal cavity 
must be protected from soiling. The retro-peritoneal 
route to the spleen seems at once the least appropriate 
and the most complicated. As described by Propping, 
who speaks favorably of it, the exposure is made through 
an incision from the tip of the twelfth rib along the lower 
margin of the eleventh rib. If need be, the twelfth and 
part of the eleventh rib may be resected. With the ringer 
as a guide, the spleen or the abscess may be reached by 
following from below upward the surface of the 
diaphragm. 

The immediate operative mortality of abscess of the 
spleen varies from about 10 to 25 per cent., being lowest 
for typhoidal abscesses, where the infection at the time of 
the operation is often attenuated. The ultimate prognosis 
must be presented in a less favorable light when the splenic 
abscess is but one of a number of pathological lesions or is 
merely an intercurrent infection in the course of a pro- 
longed or essentially chronic infection. The early recog- 
nition of the lesion and its proper management would be 
attended with a relatively low mortality were it not for 
these extraneous and coincident complications. 

The Malarial Spleen. — The removal of the spleen from 
malarial subjects is not necessarily a curative procedure, 
and the course of the disease, even to a fatal issue, may be 
uninfluenced. On the other hand, it is also true that in 
many cases removal of the spleen is followed by a general 
amelioration of the patient's condition and even by recov- 
ery. The indications for splenectomy in malarial subjects 
are threefold : a chronic malarial fever, a wandering spleen, 
and a weighty spleen, but, as the mortality is high, the 



340 THE SPLEEN AND ANEMIA 

operation should be reserved for those cases in which in- 
validism is pronounced and where there are no serious 
changes in liver or kidneys. Not only does improvement 
follow because of the elimination of an infective focus, but 
the removal of a weighty organ relieves the patient of dis- 
comfort, restores to normal the relation of the abdominal 
organs, and removes the hindrance to their circulation. 
Whether splenectomy should be encouraged in the later 
stages of malaria with ascites, a clinical state not unlike 
the third stage of Banti's disease, is open to question. 
Finkelstein, 116 who has had an unusual experience in a 
malarial climate, considers an operation advisable when 
the haemoglobin is not less than thirty or forty per cent., 
when the red blood-corpuscles are not less than 2,000,000, 
when there is no oedema of the lower limbs, when there is 
no parenchymatous lesion of the kidneys, when the patient 
is able to move about. Unfortunately, there are no means 
of determining serious degeneration of the liver, since the 
presence of a serious hepatic or renal lesion spells disaster 
after an operation. In the surviving patients the ascites 
disappears, and in two of Finkelstein's cases the fluid did 
not reaccumulate and the condition of the patient left noth- 
ing to be desired. The operative problems in malaria 
are virtually those of any disease in which there may be a 
perisplenitis and consequent adhesions. 

Tuberculous Spleen. — Tuberculosis of the spleen is 
secondary to a primary lesion elsewhere. Up to 1909, 
Fischer 118 had been able to collect but twelve cases, and 
since that time there have been but few additions. The 
operation has usually been performed because of an en- 
larged and wandering spleen and the presence of tuber- 
culosis, suspected and not discovered until examination of 
the specimen upon its removal. 



SURGICAL TREATMENT OF LESIONS 341 

Syphilis of the Spleen. — Splenectomy has been per- 
formed for both the gummatous and non-gummatous sple- 
nomegalies. Giffin 144 speaks of the advantageous removal 
of the spleen in the non-gummatous splenomegaly asso- 
ciated with syphilis. The spleen has been found to contain 
spirochetal, and after its removal there has been a rapid 
diminution in the size of a previously enlarged liver. Fur- 
thermore, whereas before the operation the Wassermann 
reaction continued positive despite appropriate treatment, 
after removal the reactions were returned as negative. 
This relationship of the spleen to the continuation of syphi- 
lis, the spleen serving as a favorable medium for the propa- 
gation of the organism, is a recent observation and is preg- 
nant with possibilities. 

Wandering Spleen. — The spleen, for various causes, 
may make wider excursions in the abdominal cavity than 
any other organ. It has been found in the sac of an ingui- 
nal hernia and often in the pelvis, where it has been mis- 
taken for uterine or ovarian tumor. It may change its 
position, as the patient moves from side to side, when it 
usually gravitates to the lowest point; it may, however, 
float upwards on the intestines; it may become fixed by 
adhesion in an abnormal position, a condition to which is 
applied the term " dislocated spleen." 

In most instances the causes of wandering spleen are 
acquired, although, in exceptional instances, congeni- 
tal elongation of the mesentery may permit of a wide 
excursion. The more common causes are accessions in 
weight, elongation of the pedicle and ligaments, and re- 
laxation of the abdominal walls often associated with vis- 
ceroptosis (Glenard's disease). Consequent upon this 
wider range of motion, which as a matter of fact occurs 



342 THE SPLEEN AND ANAEMIA 

most often in the malarial spleen, certain complications 
may develop, chief among which are engorgement and 
twists of the pedicle. The former is a gradual process and 
may add considerably to the weight of the spleen, to 
the weight of which, under normal circumstances, the blood 
contributes forty per cent. Twists or rotation of the pedi- 
cle will, of course, aggravate the engorgement and may 
in turn lead to hemorrhages, gangrene, and even peritonitis. 
The rotation may vary from 180 degrees to 360 degrees, 
and upon the suddenness and degree of rotation will de- 
pend the development of an acute or chronic symptom- 
complex. Sudden rotation of the splenic pedicle may de- 
termine an abdominal catastrophe, mistaken often for in- 
testinal obstruction or peritonitis, marked by tenderness, 
abdominal rigidity, vomiting, distention, and by the pres- 
ence of an enlarged, tender, and palpable swelling. In 
chronic cases there is not only the splenic enlargement, but, 
by virtue of its weight and displacement, the spleen may 
disturb the function of other abdominal organs. Epi- 
gastric distress, nausea and vomiting may result from 
dragging upon the stomach, and a train of symptoms from 
pressure upon the uterus and its adnexa. Not only may 
the stomach be dragged out of position, but the tail of the 
pancreas may be elongated, and the uterus displaced or 
even prolapsed. 

Theoretically, the ideal treatment of wandering spleen 
is splenopexy. This, however, presumes the presence of a 
normal organ, a condition rarely found. Since in the vast 
majority of cases wandering of the spleen is primarily due 
to splenomegaly of one variety or another, often a malarial 
spleen, splenectomy is the most satisfactory and most logi- 
cal treatment. 



SURGICAL TREATMENT OF LESIONS 343 

Tumors and Cysts. — The spleen may be the seat of 
primary or secondary growths: of the primary growths 
the adenoma, fibroma, and lymphoma have been found, but 
not on the operating table. The secondary malignant tu- 
mors of the spleen are not of practical moment, but a 
limited number of primary sarcomata have been disclosed 
at exploratory operations and removed. They take their 
origin from the capsule or trabecula, the lymphoid struc- 
ture, and the endothelial cells. One may suspect the pres- 
ence of a sarcoma of the spleen should there be an enlarged 
and tender organ, of nodular surface and firm consistency, 
with palpable notches and a rapid increase in size. Provid- 
ing metastases are not already detected, the organ should 
be removed. 

Cysts of the spleen may be large or small, of parasitic 
or non-parasitic origin. The parasitic or hydatid cyst is 
quite the most common, and its contents display the fea- 
tures characteristic of hydatid cysts elsewhere. It is inter- 
esting to note, however, that they usually originate in the 
upper part of the organ, and, as they increase in size, they 
may interfere, by pressure upward upon the diaphragm, 
with the action of both lungs and heart. When feasible, 
splenectomy is the operation of choice, but when the re- 
moval of the organ seems prohibitive from the standpoint 
of safety, the operator must be content with incision and 
drainage. 

Xon-parasitic cysts of the spleen include the dermoid, 
serous, blood and lymph cysts. The first mentioned is so 
rare as not to be of practical moment, while the others are 
often so small as to pass unrecognized. The blood cyst 
owes its origin to hemorrhage, either parenchymatous or 
subcapsular, and is often the result of an injury. A history 



344 THE SPLEEN AND ANAEMIA 

of trauma followed by the sudden appearance of a splenic 
enlargement is a significant diagnostic feature. Other 
diagnostic signs include a tumor of the left hypochondrium 
of a cystic nature, pain and tenderness, embarrassment of 
respiration if the cyst be of large dimensions, and, more 
specifically, a creaking sensation communicated to the ex- 
amining hand, as with respiration the roughened surface 
of the cyst and the abdominal wall come in contact. 

Splenomegaly, — Of the pathological conditions of the 
spleen in the treatment of which splenectomy is an accepted 
method of procedure there remain to be considered the 
splenomegalies with anaemia. The classification adapted 
in this monograph recognizes the following types : 

1. Gaucher's disease (large-celled splenomegaly). 

2. Banti's disease. 

3. von Jaksch's disease (pseudoleukemia infantum) . 

4. Chauffard-Minkowski or congenital form of haemo- 
lytic jaundice. 

5. Hayem-Widal or acquired form of hemolytic 
jaundice. 

6. Pernicious anaemia. 

These several types of splenomegaly have been treated 
in eoctenso in earlier chapters; suffice it, at this juncture, 
to speak briefly of their surgical aspects. As a general 
fundamental principle, the best results may be expected 
from splenectomy in those diseases in which there is evi- 
dence of increased blood destruction. In this category would 
fall hemolytic jaundice and some cases of pernicious anae- 
mia. Good results have also been obtained in Banti's dis- 
ease and in the few cases of Gaucher's and von Jaksch's 
disease that have been studied, but in accepting these as 
positive indications for splenectomy the proviso must be 



SURGICAL TREATMENT OF LESIONS 845 

made that promising results ean be expected in Banti's 
disease only when the operation is performed in the early 
stage. The secondary changes which take place in the liver 
of the patient with Banti's disease are not materially influ- 
enced by the removal of the spleen, and when the liver is 
obviously enlarged the propriety of the operation should be 
seriously questioned. 

In the list of doubtful indications for splenectomy I 
place pernicious ana?mia. The surgery of pernicious anae- 
mia at this writing is sub judice. As yet there have been 
no recoveries following splenectomy, although there have 
been many instances of prolongation of life, general better- 
ment of the patient's condition, and in lengthening of the 
periods of remission. The operation, therefore, is not with- 
out influence upon the course of the disease and may be 
practiced in selected cases, with the knowledge, on the part 
of the patient, that the operation is in the nature of a pal- 
liative procedure and not in any sense curative. Further- 
more, it must be borne in mind that in some cases repeated 
transfusions may be almost as effective as splenectomy, 
and that even when the latter is practiced transfusions may 
be required. 

The Removal of the Spleen 

Anatomical Considerations. — The splenic artery, itself 
a branch of the coeliac axis, divides into seven or more 
branches which supply the spleen, the pancreas, and the 
stomach. To the latter is given off the vasa brevia, passing 
between the layers of the gastrosplenic omentum to be dis- 
tributed to the great cul-de-sac, and the left gastro-epiploic, 
coursing between the layers of the great omentum to the 
greater curvature. In the operation of splenectomy the 
splenic artery is exposed for ligation in the pedicle, but 



346 THE SPLEEN AND ANAEMIA 

when ligation of the artery is to be substituted for splenec- 
tomy, the artery may be exposed, according to Gerster, 
through an opening in the lesser omentum just above the 
lesser curvature of the stomach. The first two inches of 
the artery lie just beneath the posterior parietal peri- 
toneum, and may be brought nearer the level of the anterior 
abdominal incision by placing an Edebohl cushion beneath 
the patient's back. The splenic vein, or splenic veins — 
for there are often more than one in the pedicle — unite with 
the superior mesenteric to form the portal vein, so that a 
thrombus of the latter seriously interferes with the splenic 
circulation. The pedicle of the spleen varies in length. The 
shorter the pedicle the more difficult are all the stages of 
splenectomy, including the delivery of the organ and the 
ligation of its vessels. It is comprised of connective tissue 
and fat, occasionally of lymphatic nodes, some accessory 
spleens, and the tail of the pancreas ( Plate X ) , and through 
the pedicle pass the splenic artery, and one or more veins. 
The smaller vessels to the stomach lie anterior to the ped- 
icle. In addition to the splenic artery and veins which 
enter the spleen at the hilum, there is a leash of vessels 
which enter the spleen through what Richards calls a sec- 
ondary hilum near the lower pole. These vessels are car- 
ried in a fold of peritoneum that is reflected on the surface 
of the splenic flexure of the colon. 

The capsule of the spleen is so firmly adherent to the 
surface that attempts at separation would be attended 
with laceration of the pulp ; therefore a subcapsular sple- 
nectomy is not feasible. 

A knowledge of the relationship of the spleen to the 
contiguous structures is of practical moment. The supe- 
rior pole is in close relation with the diaphragm and the 



l'Ull. X 




The relationship of the tail of the pancreas to the posterior aspect of the pedicle. 



PLATE XI 




m 




The peritoneal prolongation between the spleen and the splenic flexure of the colon, which 
must be divided before the organ can be completely mobilized. 



SURGICAL TREATMENT OF LESIONS 347 

lower pole through a peritoneal reflexion with the splenic 
flexures of the colon. In the pancreatic notch behind the 
hilum lies the tail of the pancreas, and its relation to the 
structures of the pedicle has already been mentioned. This 
is a matter of practical consideration, since, unless care be 
taken to avoid it, a portion of the tail may be amputated 
in division of the pedicle after ligation. This accident has 
occurred more than once. So close does the greater curva- 
ture of the stomach lie to the pedicle of the spleen that a 
portion of the wall has been inadvertently excised, in one 
instance with a fatal result. 

The spleen is maintained in its position under normal 
conditions by a number of ligaments, by the gastrosplenic 
ligament, the lienorenal, by an occasional band to the lower 
pole derived from the phrenocolic ligament (Plate XI), 
and by its pedicle. Under abnormal conditions — and it is 
mostly under these that splenectomy must be performed — 
the ligaments above mentioned are fortified by adhesions 
of such density and vascularity that they may make the 
operation, if not impossible, at least surrounded with many 
difficulties. The most troublesome adhesions are those 
from the outer surface and upper pole to the diaphragm, 
but there may be others to the stomach, large bowel, and 
parietal peritoneum. W. J. Mayo calls attention to the 
vascular connections in the deeper portions of the gas- 
trosplenic omentum, which pass inward and backward to 
anastomose with vessels along the spine and crux of the 
diaphragm. These vascular connections must be divided 
before the spleen can be delivered. 

Blood Transfusion. — Blood transfusion frequently may 
be called for, either in the preparation for operation or 
in the after-treatment of the splenectomized patient. Fol- 



348 THE SPLEEN AND ANiEMIA 

lowing the alarming hemorrhages of wounds and rupture 
of the spleen, the transfusion of blood, if in the emergency 
a suitable donor can be found, may be a life-saving remedy. 
In such situations the transfusion is performed immediately 
after the operation. When splenectomy is contemplated in 
the chronic case, be it Banti's disease, haemolytic icterus, 
splenic anaemia, or pernicious anaemia, transfusion plays a 
very important role in the preparation of the patient for 
operation. Should the haemoglobin be below thirty or 
forty per cent., the patient should be transfused forty- 
eight hours before the time set for the splenectomy and 
again after the operation, should the latter be attended with 
much loss of blood. It is, however, not only with reference 
to the blood picture that inquiry be made into the patient's 
condition. A careful, systematic examination of the car- 
diovascular and renal systems should be made to determine 
whether, irrespective of the anaemia, the patient be a good 
operative risk. It may well be in certain cases that a 
patient with 2,000,000 red blood-corpuscles may be a better 
hazard than one with 3,000,000 corpuscles, but with other 
handicaps. 

It is in pernicious anaemia, however, that transfusion 
plays the most important role, not only in the preparation 
of the patient for the operation — the phase of the subject 
with which we are most concerned — but also in preventing 
relapses and prolonging the period of remission. Paren- 
thetically it may be said that if no improvement follow 
transfusion little should be expected to follow a splenec- 
tomy. The effects of one may be said to forecast the effects 
of the other. Percy, whose large experience compels a hear- 
ing, has evolved a systematic method of managing the 
transfusion problem to which I attribute, in part at least, 



SURGICAL TREATMENT OF LESIONS 349 

his low mortality. He has adopted what he styles the 
step-ladder method of preparing his patients by transfu- 
sion; he prefers whole blood to defibrinated blood or blood 
treated with sodium citrate; the average number of trans- 
fusions for each patient varies from three to five, the aver- 
age amount of blood is 640 c.c, and the average interval 
between the time of the first transfusion and the splenec- 
tomy is twenty days. In almost every case improvement 
follows immediately after the first transfusion, and con- 
tinues by " step-ladder " progression with successive trans- 
fusions until the patient is in a state prepared for opera- 
tion. At the conclusion of the operation, and while still 
on the table, the patient is transfused again. According 
to Minot, the most auspicious time for the splenectomy is 
from four to ten days after the transfusion, when the 
Howell-Jolly bodies appear in greatest number, together 
with a rise in the leucocyte count and an increase in the 
blood-platelets and reticulated cells. 

The effect of transfusion upon the subject of pernicious 
anaemia varies somewhat with the stage of the disease. In 
the early cases transfusion may give a remission of several 
months and seem almost as beneficial and enduring in its 
effects as splenectomy. In the late cases the effect is only 
transitory, a matter, perhaps, of two or three weeks. But, 
while the transitory effect is fully recognized, transfusion 
should not be discarded, since it is in itself a humane meas- 
ure, giving to the patient a sense of bon feasance, increas- 
ing the appetite and general bodily comfort, and unques- 
tionably prolonging life. 

The obligation of the surgeon in the selection of a suit- 
able donor need only be mentioned. That vigilance is 
required to protect the patient from transmissible diseases 



350 THE SPLEEN AND ANAEMIA 

may be inferred from the transmission of syphilis in one 
reported case where the donor, denying exposure to infec- 
tion, had the primary lesion at the time of the transfusion. 
In the selection of a donor the matter of blood compatibility 
must be investigated with great care in order to preclude 
even the remotest possibility of haemolysis or agglutination. 
Technic of Splenectomy, — The removal of the spleen 
under certain conditions is an operation devoid of any 
peculiar difficulties. When the spleen is not enlarged, or 
when the adhesions are few and so readily divided that de- 
livery of the organ is a simple manoeuvre, splenectomy 
might be compared with an uncomplicated nephrectomy. 
The problems are somewhat similar: the manner of ap- 
proach (that is, the incision), the isolation of the organ 
and its delivery, the management of the pedicle, and the 
after-care of the wound. But the difficulties of the difficult 
splenectomy quite exceed the difficulties of the difficult 
nephrectomy, and the chief point of difference between the 
two lies in the presence of dense vascular adhesions with 
which the spleen may be surrounded. For the preferable 
line of incision one must choose a midline incision, be- 
tween an incision at the junction of the middle or outer 
third of the rectus and an incision in the linea semiluna- 
ris. Each of these incisions may have its advantages 
under certain conditions, or perhaps no one should be 
used to the exclusion of others. Personally, I prefer 
a left-sided Bevan incision, in the outer rather than 
the inner half of the rectus (Plate XII), as advocated by 
Balfour. 27 The upper limb of this incision is projected 
across the rectus an inch below the costal margin, and the 
flap thus formed, when grasped with a pair of forceps, 
may serve as a retractor. 



LATE Ml 









Left-sided Bevan incision for splenectomy. 



SURGICAL TREATMENT OF LESIONS 351 

Owen Richards 372 and Aly Bey, whose experience has 
been chiefly with large and adherent spleens of the Egypt- 
ian splenomegaly, prefer a vertical incision, stretching 
half-way between the costal angle, the lower margin of the 
thorax, about two or three inches from the median line, and 
extending downward a distance of six or eight inches. If 
the incision be in the midline, access to the outer surface 
of the spleen is not adequate, and if more external than 
the incision above described, the costal margin prevents the 
prolongation of the incision high enough to give access to 
the vault of the diaphragm. With this left rectus incision 
Richards has but once had to add a transverse cut in the 
rectus to give additional room for manipulation. 

Percy 344 has quite recently adopted a midline incision 
and claims for it advantages over those nearer the outer 
margin of the rectus. No doubt he has been influenced 
in his selection of a midline incision by his practice of 
thoroughly exploring the abdomen, particularly the region 
of the appendix and gall-bladder, in search for an in- 
fective focus as having some bearing upon the pathogenesis 
of pernicious anaemia. However this may be, he has found 
an associated lesion of the gall-bladder or appendix in 
many of his cases. In a series of twenty- four splenectomies 
he had performed twenty-one combined operations, seven- 
teen splenectomies, appendectomies, and cholecystectomies ; 
three splenectomies and appendectomies, and one splenec- 
tomy with the removal of carious teeth. 

After exploring the abdomen with particular attention 
to the condition of the gall-bladder, biliary passages, and 
the liver itself, the operator proceeds systematically to 
prepare the spleen for delivery, directing his atttention first 
to freeing its upper pole and outer surface. To accom- 



352 THE SPLEEN AND AN2EMIA 

plish this, the right hand is inserted in the left subdiaphrag- 
matic space and by blunt dissection with the fingers the 
adhesions are separated as close to the spleen as possible 
(Plate XIII). This step of the operation is perhaps the 
most difficult, because the field is not within view and hemor- 
rhage may be profuse. It may be necessary, should the 
adhesions be dense, to double-clamp and divide them with 
scissors. At this stage hemorrhage may be temporarily con- 
trolled by the use of a hot pack (Plate XIV) , postponing 
until later ligation of those points still bleeding after the 
spleen has been removed. The hot pack, a feature of W. J. 
Mayo's technique, serves a two-fold purpose : permanently 
controlling a number of the bleeding points, especially 
those of venous origin, and, secondly, serving as a support 
for the subsequent manipulation and mobilization of the 
spleen. After the adhesions to the upper and outer sur- 
faces are free and the space tamponed, the lower pole is 
drawn up and the lienorenal ligament with its vessels 
divided between two ligatures. Before the pedicle can be 
satisfactorily dealt with there remains to be divided the 
gastrosplenic omentum, between the layers of which pass 
the vasa brevia on their way to the stomach. The close 
relationship of the stomach to the spleen must be borne in 
mind at this juncture, since in the division and ligation of 
the gastrosplenic ligament the stomach may be inadvert- 
ently opened. Freed from all attachments save the pedicle, 
the spleen is now mobilized cautiously until the pedicle is 
exposed. To accomplish this >an assistant supports the 
lower pole, and the operator, with his right hand upon the 
upper pole and his left depressing the outer margin of 
the abdominal incision, by gentle traction and pressure 
manoeuvres the spleen through the abdominal wound. The 



PLATE Ml 





First step in the mobilization of the spleen. With the right hand the operator separates the 
adhesions between the superior surface of the spleen and the diaphragm. 



PLATE XIV 




To control bleeding after mobilization of the spleen a large tampon of gauze, wrung out in hot 
water, is introduced into the left hypochondrium. 



PLATE XV 






. 




Tractional ligation after isolation of the vessels of the pedicle by blunt removal of fat and 

connective tissue. 



PLATE XVI 




The double-clamp method of dealing with the pedicle. 



SURGICAL TREATMENT OF LESIONS 353 

difficulty in delivery has been said to be in direct pro- 
portion to the firmness of the adhesions and sometimes in 
inverse proportion to the size of the spleen. When the 
spleen is large and weighty sufficient support must be ap- 
plied to prevent undue traction and laceration of the struc- 
tures of the pedicle. 

The most important, though not always the most diffi- 
cult, step of splenectomy is the treatment of the pedicle. 
Grave hemorrhage may attend the process of ligation 
should the ligature slip and the vessel retract, or, after the 
patient has been returned to bed, should an insecure liga- 
ture become dislodged. As a general principle, it is a 
safer plan to ligate the pedicle in sections as the vessels pre- 
sent themselves (Plate XV), although when the pedicle 
is short it may be necessary to apply clamps and ligate 
en masse. By blunt dissection of the peritoneal covering 
and connective tissue each vessel is isolated for an inch or 
more and divided between two ligatures, the distal ligature 
being tied close to the spleen. The ligatures should be tied 
as far apart as possible and the vessel divided near the 
spleen so as to leave a long stump centralward. There are 
usually two or more veins to be dealt with and one or more 
arteries, according to whether the artery divide before it 
enters the hilum. Theoretically the artery should be tied 
first in order that the spleen may at least partially empty 
itself of its blood content. 

Fractional ligation of the pedicle must be discarded 
for ligation en masse when the pedicle is too short. Very 
much as in nephrectomies, the clamp is used when the 
pedicle is so short that the vessels cannot be easily exposed. 
Two curved rubber-covered forceps are applied to the ped- 
icle (Plate XVI) , three-quarters of an inch apart, and the 
23 



354 



THE SPLEEN AND ANAEMIA 



spleen cut away without regard to back bleeding (Mayo) , 
but after the splenic artery has been tied or clamped bleed- 
ing from the spleen itself is no great loss to the patient, 
although, as graphically described by Richards, this back 
bleeding is " mussy and demoralizing." A catgut ligature 
is thrown about the pedicle as the proximal clamp is 
loosened and the ligature tied in the compressed area. The 
distal pair of forceps is used to steady the pedicle while 
the proximal ligature is tied, and for further security a 
second ligature is employed. In the application of the 
clamps by this method the operator is again cautioned not 
to include the wall of the stomach or the tail of the pan- 
creas. After the pedicle has been ligated and the spleen 
removed the proximal stump should be given a final in- 
spection to make sure of the security of the ligature. If 
there still remain oozing points, these should be taken care 
of, and should the stump of the pedicle be broad it may 
be overrun with a fine, continuous catgut suture or covered 
with omentum. 

Gerster believes that ligation of the arterial supply 
at points more accessible than the deeply-situated splenic 
pedicle will greatly facilitate matters in difficult oper- 
ations. These points are the splenic artery close to the 
coeliac axis and the left gastro-epiploic, where it reaches 
the stomach wall. The coeliac axis is exposed and the sple- 
nic artery ligated through an opening in the lesser omen- 
tum; the left gastro-epiploic is ligated just before it begins 
to send off branches to the arteries and posterior surfaces. 
With the arterial streams under control, Gerster feels a 
greater sense of security in dealing with the vessels of the 
pedicle should difficulty be encountered or accidents hap- 
pen. After the vessels of the pedicle have been dealt with, 






SURGICAL TREATMENT OF LESIONS 355 

the preliminary ligatures of the splenic and left gastro- 
epiploic artery, if only temporary, may be released, so 
that if any arterial branches in the pedicle have been over- 
looked thejr may now be tied. There is no serious objec- 
tion, according to Gerster, to allowing the ligatures to re- 
main. While the pancreatic and vasa brevia branches of 
the splenic artery are shut off from their direct arterial 
source, the pancreas and stomach wall still have an abun- 
dant arterial supply through other branches and anasto- 
mosing relationships. This suggestion of temporary dis- 
tant ligation of the vessels may prove of service in excep- 
tional cases, but so far as I know it has not as yet been 
put into actual practice. 

The pedicle divided and the spleen removed, the hot 
pack is slowly withdrawn and an inspection made for 
points of hemorrhage from divided adhesions. These are 
best controlled with mounted ligatures. With haemostasis 
satisfactorily established, the operation is concluded by 
closure of the splenic space. This Mayo regards as ex- 
ceedingly important and introduces what he terms a 
snaking suture, as follows : 

' With catgut on a small curved needle, the raw space 
beginning at the tied splenic vessels is closed as well as 
possible. The margin of the lienorenal ligament, on the 
outer side, is sufficiently firm to hold a suture, but on the 
inner side such bits of tissue must be caught here and there 
as can be done safely until the bleeding vessels are com- 
pressed. The last sutures come well down in the dia- 
phragm and had best be applied during cardiac diastole 
and during expiration." 

The purposes of the operation fulfilled and the field 
dry, the wound is closed without drainage, although to 



356 THE SPLEEN AND ANAEMIA 

this general rule exceptions may be taken — on the one 
hand if the wound be not entirely dry, or if the field may 
have been soiled by an accidental injury to stomach or 
colon. 

For many reasons the most serious complication of 
splenectomy is hemorrhage. The fragility of the splenic 
veins exposes them to laceration when too much traction is 
put upon the pedicle; in the case of an atheromatous 
splenic artery a ligature may tear through; should a liga- 
ture or clamp slip from the pedicle the stump of the divided 
vessel quickly retracts beneath the costal margin; in the 
separation of adhesions the capsule may be torn and the 
splenic pulp bleed freely; the adhesions themselves may 
be extremely vascular and contain a well-developed artery 
and a number of varicose veins ; ligation of the vasa brevia 
or the gastrosplenic omentum may be troublesome. The 
spleen itself has been described as an elastic bag full of 
blood under pressure, and the splenic vessels, when cut, 
bleed furiously from either end. Its blood content equals 
forty per cent, of its weight, and this in enlarged spleens 
may amount to more than a quart. It matters little, how- 
ever, whether the artery or vein be first ligated : the amount 
of blood it contains after removal is practically the same in 
either case. 

While the sources of hemorrhage are many, the im- 
pression must not be gained that a splenectomy is usually 
attended with the loss of a considerable quantity of blood. 
In the absence of adhesions I have completed the operation 
with the loss of not more than two teaspoonfuls of blood, 
and, though the potential sources of hemorrhage are 
numerous, with careful attention to methods of preven- 
tion and to methods of control, even in difficult cases, the 



SURGICAL TREATMENT OF LESIONS 357 

loss of blood may be within reasonable limits. I have had 
no experience with the preoperative administration of 
adrenalin, which is said to cause marked shrinkage of the 
organs, but have been content with the effect of normal 
saline solution, intravenously or with blood transfusion, 
when the amount of blood lost at the operation might retard 
the patient's convalescence. In cases of pernicious anaemia 
Percy 344 routinely transfuses the patient while still on the 
operating table. 

As complications of splenectomy, apart from hemor- 
rhage, should be mentioned injuries to adjacent viscera. 
Mention has been made of the proximity of the stomach 
and of its occasional injury during splenectomies and of 
the intimate relationship of the tail of the pancreas to the 
pedicle and hilum. Even when a portion of the tail of the 
pancreas has been included in the ligature of the pedicle, 
no serious consequences, such as fat necrosis from the pan- 
creatic secretion, have been reported. 

The operative sequelae of splenectomy are varied. With 
the exception of shock and collapse, as in cases of grave 
hemorrhage, the most frequent complication is bronchitis 
or pneumonia. The susceptibility of the splenectomized 
patient to infection is a factor to be reckoned with, but this 
alone does not explain why the lung should be the site of 
election for the coincident infection. Nor can the relative 
frequency of pneumonia be attributed to a transitory para- 
lysis of the diaphragm, because these pneumonias develop 
on the right side as well as the left. Whatever may be the 
cause, the fact remains that pneumonia is a common com- 
plication ; and in one of my cases, a splenectomy for Banti's 
disease, the patient developed after the pneumonia a pneu- 
mococcic peritonitis, from both of which, however, she 



358 THE SPLEEN AND ANAEMIA 

made an excellent recovery. Of the causes of death other 
than those attributable to the anaemia, I may mention shock, 
pain, hemorrhage, pneumonia, suppression of urine, mesen- 
teric thrombosis, portal thrombosis, and acute dilatation of 
the stomach. 

The operative risks of splenectomy must of necessity 
vary widely; the condition of the patient at the time of 
operation, the disease from which the patient is suffering, 
and, more particularly, the stage of the disease at which 
the operation is performed, the care and judgment exer- 
cised in the selection of cases, not to mention the skill and 
experience of the operator — these and other factors affect 
the mortality. As our knowledge of the indications for 
operation has developed, as our judgment in the selection 
of cases has grown riper, as the advantages of transfusion 
have been made use of in the preparation of our patients 
and their after-care, as the pitfalls are recognized and the 
means of avoidance understood, the mortality of splenec- 
tomy has been very materially reduced. 

The largest number of splenectomies by a single oper- 
ator was the series of Finkelstein, 116 who recorded his 
mortality for 66 cases from 1903 to 1913 as 38 per cent. 
Carstens collected & series of 739 splenectomies with a 
mortality of 27.4 per cent. In a series of 75 splenectomies 
in malarial subjects, representing six operators, the death- 
rate was 34.7 per cent. That the risk of this operation 
can be and has been reduced materially may be inferred 
from the reports of more recent experiences with pernicious 
anaemia when the mortality rate has been reduced to 8 per 
cent. This has been made possible by a clearer under- 
standing of the problems of the operation, by the judicious 
employment of transfusion, and greater care in the selec- 
tion of cases, 



BIBLIOGRAPHY 



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362 THE SPLEEN AND ANAEMIA 

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53 Botazzi: La Milza come Organo Emocatatonistico. Lo Speri- 
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54 Bovaird, D., Jr. : Primary Splenomegaly — Endothelial Hyper- 
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55 Bozzolo: Fol. Haamistol., 1910, x, 179, II Teil Zent. Org. 
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56 Breccia, G. : Lesioni epatiche sperimentali di origine splenica. 

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57 Brikl, N. E., and Mandlebaum, F. S. : Large-cell Spleno- 

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58 Brile, N. E. : Report of a Case of Pernicious Anaemia. Tr. 

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59 Brissaud and Bauer : Recherches sur la resistance des globules 

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60 Brogsitter, C. M. : Splenektomie bei traumatische Milzruptur. 

Charite Annalen, 1908, xxxiii, 494. 

61 Buerger, L., and Ottenberg, R. : Transfusion and Splenec- 

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62 Bulgak, J. : Ueber die Contractionen und die Innervation der 

Milz. Virchow's Arch., 1877, lxix, 181. 



366 THE SPLEEN AND ANAEMIA 

63 Bunting, C. H. : Experimental Anaemias in the Rabbit. Jour. 

Exper. Med., 1906, viii, 625; ibid., The Etiology and 
Pathogenesis of Pernicious Anaemia. Johns Hop. Hosp. 
Bull., 1905, xvi, 222 ; ibid., Experimental Anaemia. Jour. Am. 
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64 Bychowski, Z. : Zur Kasuistik der heredof amiliaren Spleno- 

megalie. Wein. klin. Woch., 1911, xxiv, 1519. 

65 Cabot, R. C. : In Osier and McCrae. Modern Med., 2nd ed., 

iv, 639. 

66 Cantieri, C. : Die Cholesterintherapie in einem Fall v. Anamie 

Splenica im Kindesalter. Rass. di clin. terap. e. sci. aff., 
1913, xii, 342 (Abstr. Cent. f. d. ges. im Med., 1914, viii, 
643). 

67 Cateliani, S. : Sopra una splenectomia per Milza mobile ma- 

larico — Considerazioni sulla splenectomia e splenoplesia. 
Gaz. d. Ospedali, 1897, xviii, 75. 
68 Cavazza, E.: Gli Itteri Emolitica. Milano, 1911. 

69 Ceresole, G. : De La Regeneration de la rate chez le lapin. 

Beitrage z. path. Anat. u. z. allge. Path., 1895, xvii, 602. 

70 Cetti and Breithaupt (see Sherman) : Chemistry of Pood and 

Nutrition. New York, 1915, p. 247. 

71 Chalier, J., and Char let, L. : Etat de la resistance globulaire 

chez l'animal normal et splenectomise. Jour, de physiol. et 
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72 Chauffard, A. : Pathogenie de l'ictere congenitale de l'adulte. 

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73 Chauffard, A., and Fiessinger, N. : Ictere Congenital hemoly- 

tique avec Lesions Globulaires. Bull, et Mem. Soc. Med. des 
Hop. de Paris, 1907, xxiv, 1169. 

74 Chauffard, A., and Laroche, C, and Grigaut: Le Taux de 

la cholesterinemie au cours des cardiopathies chroniques et 
des nephrites chroniques. Comp. rend. soc. Biol., 1911, lxx, 
108. 



BIBLIOGRAPHY 367 

75 Chauffard, A., and Troisier: Das Rapports dc ccrtaines 
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7G Chauffard, A., and Vincent: Hemoglobinurie hemolysinique 
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77 Clark, E. C. : Splenic Anaemia with Splenectomy. Amer. Jour. 

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78 Clarke, T. : Ephemerid. Natur. Curios. Ann. iv, and (1673 

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79 Claus and Kalberlah : Ueber chronischen Icterus. Berl. klin. 

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80 Closson, O. E. : The Elimination of Creatinin. Amer. Jour. 

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81 Coleman, W. : Splenectomy for Pernicious Anaemia. Tr. Assn. 

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82 Collier : Splenectomy : A Justifiable Operation in Leucocy- 

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83 Comelli, V. : Influenza dell' asportazione della Milza nella In- 

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84 Cominotti, V. : Hyperglobulie and Splenomegalie. Hyper- 

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85 Czermak, J. J. : Versuche iiber die Extirp. der Milz. Med. 

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86 Dahl, R. : Om Behandling an den Perniciosa Anamien med. 

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87 Danilewsky, B. : Ueber die blutbildende Eigenschaf t der Milz 

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264. 



368 THE SPLEEN AND ANAEMIA 

88 Darling, C. G. : Non-parasitic Cyst of the Spleen; Splenec- 
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89 Daumann, A.: Ueber die nosologische Stellung des Hamoly- 
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90 Dawson, B.: Enlarged Spleen: Cirrhosis of Liver; Splenec- 
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91 v. Decastello, G. : Discussion of Kahn's case. Verhand. d. 

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92 v. Decastello, G. : Ueber den Einfluss der Milzextirpation auf 

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93 Dickson, W. E. C. : The Bone-marrow. New York, Bombay 

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94 Doeeinger : Jahresb. f. Chir., 1903 (quoted by Isaac, refer- 

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95 Domenici : Sur l'histologie de la rate a l'etat normal et patholo- 

gique. Arch. med. exp. d'anat. path., 1901, xiii, 1. 

96 Donhauser, J. L. : The Human Spleen as an Hasmatoplastic 

Organ, as Exemplified in a Case of Splenomegaly with Scle- 
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97 Doring, O. : Dissertation Konigsberg, 1909. Bantische Krank- 

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98 Dowd: Discussion of Kammerer's case. Ann. Surg., 1909, 1, 
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"Dubin, H., and Pearce, R. M.: A Note on the Blood Fat Be- 
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100 Eberhard : Beitrage zur Morphologie und Funktion der Milz. 

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101 Edens, H. : Ueber Milzvenenthrombose, Pf ortaderthrombose 

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Chir., 1907, xviii, 59. 



BIBLIOGRAPHY 369 

102 Elliott, and Kaxavel, A. B. : Splenectomy for Hemolytic Ic- 

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103 Emeliaxow, P.: Sur le role de la rate au point de vue de la 

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105 Eppixger, H., and Raxzi, E. : Ueber Splenektomie bei Bluter- 

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106 Erdmax, J. F., and Moorhead, J. J. : Splenectomy for Spleno- 

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107 Eterxod : Sur un Case de Regeneration de la Rate a la Suite 

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103 Evaxs, F. A. : The Reaction of the Spleen in Acute Infections. 

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109 Fahreus, M. B.: Tre Fall av Pernicios Aaiamie, behandlade 

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110 Faltix, R. : Milzartige Bildungen im Peritoneum. Deuts. 

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111 Fexckel: Discussion of article by Kreuter on Experimentelle 

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112 Ferrerius, Gerbezus, South-Wilson (quoted by Brogsitter, 

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113 Fevrier, C. : La Chirurgie de la Rate. Cong. Franc, de Chir., 

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114 Flexxer, S. : The Pathology of Lymphotoxic and Myelotoxic 

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Also Bunting, C. H., The Effects of Lymphotoxins and 
24 



370 THE SPLEEN AND ANAEMIA 

Myelotoxins on the Leucocytes of the Blood and the Blood- 
forming Organs. Univ. of Penna. Med. Bull., 1903-04, xvi, 
200. 

115 Florcken : Discussion of article by Kreuter. Verhandl. d. 

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116 Finkelstein, B. K. : On the Surgery of the Spleen. Brit. 

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117 Fioravanti : Tesoro della vita humana. Lib. II, Cap. 8 

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118 Fischer, V. : Ein Beitrag zur Kenntnis der isolierten Milz- 

tuberkulose. Wien. med. Woch., 1909, lix, 2505. 

119 Foa, P. : Beitrag zum Studium des Knochenmarks. Beitrage 

z. path, anat., 1899, xxv, 376. SulP ematopoesi e la funzione 
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366. 

120 Folin, O. : Eine neue Methode zur Bestimmung des Ammoniaks 

im Harne, und anderen thierischen Flussigkeiten. Ztschr. f. 
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121 Folin, O. : Approximately Complete Analyses of Thirty " Nor- 

mal " Urines. Am. Jour. Physiol., 1905, xiii, 45. 
122 Folin, O., and Wentworth, A. H. : A New Method for the 

Determination of Fat and Fatty Acids in Faeces. Jour. Biol. 

Chem., 1909-10, vii, 421. 
123 Foein, O., and MacCalltjm, A. B., Jr.: A New Method for 

the (Colorimetric) Determination of Uric Acid in Urine. 

Jour. Biol. Chem., 1912-13, xiii, 363. 
124 Folin, O., and Denis, W. : On the Colorimetric Determination 

of Uric Acid in Urine. Jour. Biol. Chem., 1913, xiv, 95. 
125 Folin, O., and Denis, W. : On Creatine in the Urine of Chil- 
dren. Jour. Biol. Chem., 1912, xi, 253. 
126 Fowler, R. S. : Movable Spleen. Jour. Am. Med. Ass'n., 

1914, lxii, 198. 
126a Fowler, R .S.: Splenectomy for Splenic Anaemia. N. Y. St. 

Jour. Med., 1914, xiv, 435. 



BIBLIOGRAPHY 371 

127 Fran genheim: Sitz. d. allg. Aerzt. Vcr. z. Koln. Miinchen. 

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127a Freiberg: Dissertation. Dorpat, 1891; cited by Taylor, 
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128 French, H., and Turner, P. : Case of Splenic Anaemia treated 

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129 Freund, H. A., Rexford, W. K. : Serologic Examinations in a 
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130 Freyer, M. : Ueber die Betheiligung der Milz bei der Entwicke- 

lung der rothen Blutkorperchen. Dissert., Konigsberg, 1872. 

131 Friedman, G. A., and Katz, E. : Reports of a Case of Acquired 

Hemolytic Jaundice with Splenectomy. Jour. Am. Med. 
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132 Fuhrer and Ludwig : Ueber die Milz einige Besonderheiten 

ihres Capilar systems. Vierordt's Arch. f. Phys. Heilk., 
1855, xiv, 149. 
133 Fuhs, J.: A Case of Banti's Disease. Splenectomy followed 
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134 Furno, A. : Ricerche sperimentali ematologiche, edanatomo- 

patalogiche intorno all' emolisi do siero, negli animali nor- 
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135 Gabbi, U. : Die Blutveranderungen nach Extirpation der Milz 

in Beziehung zur hamolytischen Function der Milz. Beitrage 
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1893, xiv, 351. 

136 Gaisbock, F. : Beitrag zur Klinik hamolytischer Anamien mit 

herabgesetzter osmotischer Erythrocytenresistenz. Deut. 
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137 Gates, F. L. : Observations on Splenectomized Dogs. A. The 

Resistance of the Bed Blood-cells to Shaking. B. The Effect 



372 THE SPLEEN AND ANAEMIA 

of Repeated Bleedings of Small Amount a Year or More 
after Splenectomy. Read at meeting of Am. Soc. for Exp. 
Pathology, New York, Dec. 29, 1916. 

138 Gandy, C. et Brule, M. : Ictere Hemolytique Congenitale Au- 

topsie. Bull, et Mem. Soc. Med. des Hop. de Paris, 1909, 
xxviii, 369. 

139 Gaucher, E.: De l'Epithelioma primitif de la rate. These de 

Paris, 1882. 

140 Gibson, J. L. : The Blood-forming Organs and Blood Forma- 

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* 41 Gibson, A. G. : On Certain Causes of Splenomegaly and Banti's 
Disease. Proc. Roy. Soc. Med. Sect., 1914, vii, 7. 

142 Giffin, H. Z. : Clinical Observations Concerning Twenty-seven 

Cases of Splenectomy. Amer. Jour. Med. Sci., 1913, cxlv, 
781. 

143 Giffin, H. Z. : Personal communication to the author. 

144 Giffin, H. Z. : Splenectomy for Splenic Anaemia in Childhood 

and for the Splenic Anaemia of Infancy. Am. Surg., 1915, 
lxii, 679. 

145 Gilbert, Q. O. : The Occurrence of Nuclear Changes in the 

Red Blood-cells following Splenectomy. Arch. Int. Med., 

1917, xix, 140. 
146 Gilbert, A.: Cholemie Familiale. Bull. Mem. Soc. Med. des 

Hop. de Paris, 1907, xxiv, 1203. (N. B. — This contains 

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146a Gilbert, A., and Lereboullet, P.: Contribution a L'Etude 

des Angiocholecystitis Chroniques. Bull, et mem. Soc. Med. 

des Hop. de Paris, 1903, xv, 385. 

147 Goebel, W. : Zur operativen Behandlung der Bantischen 

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148 Goldman, C. : Zur Kasuistik der Milzvenen-u. Pf ortaderthrom- 

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149 Goldschmidt, S., and Pearce, R. M. : Studies of Metabolism 



BIBLIOGRAPHY 373 

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150 Goldschmidt, S., Pepper, O. H. P., and Pearce, R. M.: Me- 
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151 Gottlieb, R. : Ueber die Ausscheidungsverhaltnisse des Eisens. 
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152 Graf, P.: Zur Chirurgische Therapie des hamolytischen Ik- 
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153 Graff: Ueber Milzextirpation bei Anaemia pseudoleukemia in- 
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154 Gretsel : Ein Fall von Anaemia splenica bei einen Kinde. Berl. 

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155 Grigorescu : I. Sur le Role Hemopoietique de la rate. Arch. 

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156 Grosser, and Schaub, G. : Zur Pathologie des Morbus Banti. 

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157 Groves, E. H. : Splenectomy in Banti's Disease. Bristol Med. 

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158 Guinon, L., Rist, E., Simon, L. G. : Splenomegalie chez une 

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159 Guleke: Discussion of article by Kreuter. Verhandl. d. 

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160 6unn, J. A., and Feltham, W. J.: The Antihemolytic Power 

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161 Haal: Quoted by Minkowski in Modern Clinical Medicine; 

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162 Hall, F. D., and Spencer, W. G. : Splenectomy for Splenic 

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163 Halpern, M.: Zur Frage der Stickstoffvertheilung im Harn 



374 THE SPLEEN AND ANAEMIA 

in pathologischen Zustanden. Ztschr. f. klin. Med., 1903, i, 
355. 

164 Hamburger, E. W. : Ueber die Aufnahme und Ausscheidung 

des Eisens. Ztschr. f. Physiol. Chem., 1878-79, ii, 191. 

165 Hamburger, H. J. : Osmotischer Druck und Ionerlehre, i, p. 

164. 

166 Hansing, W. : Die Milzextirpation bei pernizioser Anamie. 

Med. Klin., 1914, x, 1544. 

167 Harmens, W. : A Case of Acholuric Jaundice Cured with Sple- 

nectomy. Lancet, 1915, i, 749. 
168 Harpole, W. S., and Fox, C. M. : Case of Pernicious Anaemia 
Treated by Splenectomy. Marked Improvement. Surg., 
Gynec. and Obstetrics, 1914, xviii, 243 ; later reports by per- 
sonal communication to the author. 

169 Harris, and Herzog, M. : Splenectomy in Splenic Anaemia or 

Primary Splenomegaly. Ann. of Surg., 1901, xxxiv, 111. 

170 Hausermann, E. : Die Assimilation des Eisens. Zeits. f . Phys. 

Chem., 1897, xxiii, 555. 

171 Hayem, C. : Nouvelle Contribution a l'Etude de l'Ictere Inf ec- 

tieux Chronique Splenomegalique. Bull, et Mem. Soc. Med. 
des Hop. de Paris, 1908, xxv, 122. 

172 Heaton, G. : A Successful Case of Splenectomy for Rupture. 

Brit. Med. Jour., 1899, ii, 476. 

173 Henderson, L. J., and Palmer, W. W. : On the Intensity of 

Urinary Acidity in Normal and Pathological Conditions. 
Jour. Biol. Chem., 1912-13, xiii, 393. 

174 Henderson, L. J., and Palmer, W. W. : On the Several Fac- 

tors of Acid Excretion. Jour. Biol. Chem., 1914, xvii, 305. 

175 Herrmann, C. : A Case of Gaucher's Disease. Med. Rec, 

1914, lxxxvi, 606. 

176 Herrmann, C, Roth, N., and Bernstein, E. P. : A Case of 

Gaucher's Disease in a Boy 13 years of age. Splenectomy 
with Recovery. Arch, of Ped., 1914, xxxi, 340. 
177 Herrick, F. C. : Splenic Anaemia with Splenectomy (Banti's 
Disease) . Ann. Surg., 1914, lix, 690. 



BIBLIOGRAPHY 375 

178 Hirschfeld, H. : Zur pathologischen Anatomic der Plethora 

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179 Hirschfeld, H. : Die Funktion der Milz. Deut. med. Woch., 

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180 Hirschfeld, H., and Weinert, A.: Klinische und experimen- 
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181 Hodenpyl, E. : A Case of Apparent Absence of the Spleen 

with General Compensatory Lymphatic Hyperplasia. Medi- 
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182 Hoffmann, G. : Splenic Anaemia Treated by Splenectomy. 

Proc. Roy. Soc. Med., 1913-14, vii, Clin. Sect. 78. 

183 Hollins, T. J. : Primary Splenomegaly or Splenic Anaemia : A 

Critical Study with Special Reference to Pathogenesis. 
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184 Hopkins, A. H. : Two Instances of Chronic Family Jaundice. 

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185 Horz, W. : Ueber Splenektomie bei traumatischer Milzruptur 

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186 Hossli, H. : Bericht iiber einen Fall von Milzextirpation bei 
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187 Huber, O. : Ueber den Einfluss der Milzextirpation bei per- 
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188 Hunter, W. : Pernicious Anaemia; Its Pathology, Septic Ori- 
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189 Hunter, W. : Lectures on the Physiology and Pathology of 
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190 Hutchinson, J.: Excision of the Spleen for Splenic Anaemia. 
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191 Hynek, K. : Chronischer Ikterus mit Milztumor ohne Bilirubi- 



376 



THE SPLEEN AND ANAEMIA 



nurie Casopis lekaro ceskych., 1906, 1029 (Ref. Schmidt's 
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192 Hyrtl: Handb. d. topograph. Anat., 1853, ii, 440. 

193 Isaac, S. : Der Bantische Symptomencomplex und seine Stel- 

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194 Iscovesco, H. : Les Lipoides du Sang. La Cholesterine. 

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195 Iscovesco, H. : Etudes sur les lipoides de l'organisme la ferro- 

lecithine la cholesterine. Comp. rend. Soc. Biol., 1907, lxiii, 
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196 Iscovesco, H., and Zacchiri, E.: Sur le pouvoir autohemoly- 

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197 Jaffe: Ueber den Werth der Milzextirpation bei der Ban- 
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198 v. Jagic, N. : Milzextirpation bei Pernicioser Anemie. Wien 

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199 Jakoby, M. : Zur Kenntnis der alkohollosichen Hamolysine bie 

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200 Joannovics, G. : Experimentelle Untersuchungen iiber Ikterus. 

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201 Joannovics, G., and Pick, E. P.: Beitrag zur Kenntnis der 

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202 Johnston, G. B. : Splenectomy with a statistical summary of 

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203 Jona, G. : Policlinico, 1916, xxxiii. 



BIBLIOGRAPHY 377 

204 Judell: Personal communication from Dr. Moffitt to the 
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205 Julliex, L. : Valeur de la splenectomie dans le Traitment des 

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206 Kahn : Ueber hemolytischen Iktcrus und seine Beeinflussing 

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210 Karsxer, H. T., and Pearce, R. M. : The Antibodies Produced 

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211 Kidd, F. : Case of Banti's Disease Cured by Splenectomy. 

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213 King, J. H. : Studies in the Pathology of the Spleen. Arch. 

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214 Kirschxer, M. : Der Gegenwartige Stand und die nachsten 

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215 Kleixschmidt, H. : Aplastische (aregenetorische) Hamoly- 

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lxxxi, 1. 



378 THE SPLEEN AND ANAEMIA 

216 Klemperer, G., and Hirschfeld, H. : Milzextirpation zur 

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217 Klemperer, G., and Muhsam, R. : Anaemia splenica geheilt 

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218 Knott, Y. B. : Splenic Anaemia in a Five-year-old Boy. Jour. 

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219 Knox, J. H. M., Jr., Wahl, H. R., and Schmeisser, H. C. : 

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220 Kohan, J. : Ueber die Milzextirpation bei Pernizioser Anamie. 

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221 Kohlhaas: Volliger Mangel der Milz. Med. Correspond, d. 
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222 Kolmer, J. A. : Venom Haemolysis after Splenectomy, Includ- 
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223 Kolmer, J. A., and Pearce, R. M. : Studies in Non-Specific 
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224 Korenchevski, V. G. : Nitrogenous and Gaseous Metabolism 

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225 Korschun, S., and Morgenroth, J. : Ueber die hamolytischen 

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226 Krumbhaar, E. B. : Adapted from a sketch by E. B. Krumb- 

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227 Krumbhaar, E. B., Musser, J. H., Jr., and Pearce, R. M. : 

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380 THE SPLEEN AND ANEMIA 

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250 Lintwarew, J. : Die zerstorungcn der ery throcyten in Milz unci 
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382 THE SPLEEN AND ANAEMIA 

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285 Mendel, L. B., and Jackson, H. C. : On Uric Acid Formation 

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384 THE SPLEEN AND ANAEMIA 

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25 



386 THE SPLEEN AND ANEMIA 

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388 THE SPLEEN AND ANAEMIA 

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349 Peybani : Sur la non-regeneration de la rate. Comp. Rend, de 

PAcad. de Sciences, 1866, Ixii, 89. 

350 Phillippeaux, J. M. : Note accompagnant la presentation de 

plusieurs pieces relatives a la regeneration de la rate. Comp. 
Rend, de l'Acad. de Sciences, 1861, Hi, 547. 

351 Philippeaux, J. M. : Note sur la regeneration de la rate. 

Comp. Rend, de l'Acad. de Sciences, Dec. 11, 1865, lxi, 1058. 

352 Picard and Malassez : Sur les f onctions de la rate. Gaz. med. 

de Paris, 1878, vii, 317. 

353 Pick, A. : Ueber hereditaren Ikterus. Wien. klin. Woch., 1903, 

xvi, 493. 
354 Pickard, R. J.: Polycythemia. Jour. Am. Med. Ass'n., 1916, 

lxvii, 1845. 
355 Plehn, A. : Familiare Milz- und Lebervergrosserung mit Ana- 

mie und gutartigen Verlauf. Deut. med. Woch., 1909, xxxv, 

1749. 
336 Pliny, C: Sec. Historia Naturalis. Bk. XI, c, 37, p. 611 

(Elzevier, 1635). 

357 Peiny, C. : Sec. Historie of the World, commonly called " Natu- 

rall Historie," etc., translated by P. Holland, p. 343 (A. 
Islip, London, 1601). 

358 Ponfick, E. : Ueber Haemoglobinaemie und ihre Folgen. Berl. 

klin. Woch., 1883, xx, 389. 

359 Pool, E. H. : Splenectomy for Banti's Disease, Ante-operative 

Transfusion. Ann. Surg., 1914, lx, 769. 
359a PooL, E. H. : Transfusion and Splenectomy for v. Jaksch's 
Anaemia in an Infant. Ann. Surg., 1915, lxi, 349. 

360 Port, F. : Beitrag zur Behandlung der Perniziose Anaemie 

durch Milzextirpation. Berl. klin. Wochenschr., 1914, li, 
546. 

361 Pribram, B. O. : Hypersplenische Hamophthisen und Stau- 

ungsmilz. Wien. klin. Woch., 1913, xxvi, 1607. 



390 THE SPLEEN AND ANAEMIA 

362 Prince, E. M. : Case Reports of Surgery of the Spleen. Jour. 

Am. Med. Ass'n., 1915, lxiv, 1571. 

363 p UGLIESE? A. : Ueber die physiologische Rolle der Riesenzellen. 

Fortschr. der Medicin, 1897, xv, 729. 

364 Puguese, A., and Luzzatti, T. : Contributo alia fisiologia della 

Milza — Milza e veleni ematici. Archivio per le Scienze Med- 
iche, 1900, xxiv, 1. Resume of same: Rate et Poisons hema- 
tiques. Arch. ital. de Biol., 1900, xxxiii, 349. 

365 Pugliese, A.: Die Absonderung und Zusammensetzung der 

Galle nach Extirpation der Milz. Arch. Anat. u. Physiol., 
1899 (Physiol. Abth.), p. 60 ; La secrezione e la composizione 
della bile negli animali smilzati. Policlinico, 1899, vi (Sez. 
Med.), 121. Resume of same : La Secretion et la composition 
della bile les animaux prives de la rate. Arch. ital. de Biol., 
1900, xxxiii, 359. 

366 Puresoff, S. : Banti's Disease, with Description of a Case 

Where the Patient Recovered after Splenectomy, quoted In- 
dex Med. 1912. Med. Obozr., Mosk., 1911, lxxv, 1091. 

367 Quadri, G. : Splenomegalia emolitica con itterizia acoluria in- 

tercorrenta. Annal. di Clin. Med., 1913, iv, 179 (N. B., also 
in Virch. Arch., 1914, ccxv, 151). 

368 Quittenbaum, K. S. : Commentarii de Splenic hypertrophic et 

historia extirpationis. Rostock, 1836 (not available, quoted 
by Simon, 1. c). 

369 Racoviceantj : La Chirurgie de la Rate. Bull, et Mem. Soc. 

de Chir. de Chir. de Bucaret, 1901, iv, 65. 

370 Ribierre, P. : L'hemolyse et la mesure de la resistance globu- 

laire. These de Paris, 1903. 
071 Richards, E. F., and Johnson, W. C. : A Study of a Case of 
Congenital Hemolytic Jaundice. Jour. Am. Med. Ass'n., 
1913, Ixiii, 1586. 

372 Richards, O. : Splenectomy in Egyptian Splenomegaly. Brit. 

Jour. Surg., 1913-14, i, 428. 

373 Riches, R. G. : A Case of Congenital Absence of the Spleen. 

Jour. Ment. Sci., 1914, lx, 630. 



BIBLIOGRAPHY 391 

37 *Richet, C. : Des effeta de l'ablation de la rate sur la nutrition 
chez les chiens. Jour, de Phys. et de Path, gen., 1912, xiv, 
689 ; Des effets de l'ablation de la rate sur la nutrition Deux- 
ienne memoire., 1913, xv, 579. 

875 Riegner, O. : Ueber einen Fall von Extirpation der traumat- 
isch zerrissenen Milz. Berl. klin. Woch., 1893, xxx, 177 

376 Ripper and Schwarzer: See Neuberg, C. Der Harn. Berl., 

1911, I Teil, 162. 

377 Roberts, T. S. : The History of a Case of Splenic Anaemia, 

Including Early Splenectomy and Autopsy Two Years Later. 

Jour. Lancet, 1915, n. s. xxxv, 439. 
878 Robertson, O. H. : Urobilin in the Stool in Pernicious Anaemia, 

as Influenced by Splenectomy, Transfusion and Salvarsan. 

Arch. Int. Med., 1915, xvi, 429. 
379 Robertson, O. H. : A Study of the Haemolytic Activity of the 

Spleen in Pernicious Anaemia. Arch. Int. Med., 1915, xvi, 65. 
380 Roblee, W. W. : Journal of Am. Med. Ass'n., 1915, lxiv, p. 

796 ; personal communcation to the author. 

381 Rodman, J. S. : Personal communication to the author. 

382 Rodman, J. S., and Willard, DeF. P. : Splenic Anaemia with 

Special Reference to Etiology and Surgical Treatment. Ann. 
Surg., 1913, lviii, 601. 
383 Roemer: Drei Falle von Milzextirpation. Berl. klin. Wchnsr., 
1914, li, 669. 

384 Rosenqvist, E. : Ueber den Eiweisstoffwechsel bei der per- 

niciosen Anamie, mit specieller Beriicksichtigung der Bothrio- 
cephalus Anamie. Ztschr. f. klin. Med., 1903, xlix, 193. 

385 Roth, O. : Ueber merkwiirdige Erythrozyteneinschliisse bei 

einem Fall von Milzextirpation (Zugleich ein Beit rag zur 
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1912, lxxvi, 23. 

386 Roth, O. : Ueber die hemoly tische Anamie. Deut. Arch, f . klin. 

Med., 1912, cvi, 136 ; Der Angeborene hemoly tische Ikterus, 
Correspbl. q. schweiz. Aertz., 1913, xliii, 689. 



392 THE SPLEEN AND ANAEMIA 

387 Roth, O. : Zur Frage des " Ictere hemolysinique " (Chauffard). 
Deut. Arch. klin. Med., 1913, ex, 77. 

387a Rous, Peyton and Robertson, O. H. : The Normal Fate of 
Erythrocites. I. The Findings in Healthy Animals. Jour. 
Exper. Med., 1917, xxv, 651. II. Blood Destruction in Ple- 
thoric Animals and in Animals with a Simple Anaemia, ibid., 
1917, xxv, 665. 

388 Rousset: " Traite nouvelle d'hysteroto-motokie. Paris, 1581, 
80, Sect. IV, 6, iv (quoted by Simon). 

389 Rummo, G. : Sulle Emopatie Splenomegaliche. Rif . Med., 

1914, xxx, 897. 

390 Sailer, J. : Banti's Disease. Report on Operative Cases. 

Penna. Med. Jour., 1914-15, xviii, 92. 

391 Samuely, F. : Stoffwechseluntersuchungen bei experimenteller 

Anamie. Deutsch. Arch. f. klin. Med., 1906, lxxxix, 220. 

392 Sargent, P. : Case of Splenic Anaemia Treated by Splenectomy. 

Proc. Roy. Soc. Med., 1913-14, vii, Clin. Sec, 76. 

393 Schiassi, B. : La Splenocleisis contre l'Anemie Splenique et la 

Maladie de Banti. Sem. Med., 1906, xxvi, 73. 

394 Schloffer, Zwei Falle von Morbus Banti bein denen die Milz 

extirpiert worden. Wien. klin. Woch., 1912, xxv, 1210. 

395 Schmidt, M. B. : Ueber die Organe des Eisenstoffwechsels und 

die Blutbildurig bei Eisenmangel. Verhandl. d. Deutsch. 
path. Gesellsch., 1912, xv, 91. 

396 Schneider, J. P. : The Splenic Pathology of Pernicious Anae- 

mia and Allied Conditions. Arch. Int. Med., 1916, xvii, 32. 

397 Schneider, J. P. : Further Quantitative Study of the Duode- 

nal Blood-derived Pigments. Arch. Int. Med., 1917, vol. 
xix, p. 156. 

398 Schultze, J. H. : Diss, de splene caribus exciso et ab his exper. 

cap. fructu (not available, quoted by Simon). 

399 Schultze, A. S. : Ueber die Verrichtung der Milz und die Ex- 

tirpation derselben bei Thieren und dem Menschen. Hecker's 
Litterariche Annalen der ges. Heilk., 1828, Bd. xii, 385. 



BIBLIOGRAPHY 393 

400 Schumann, A.: Die neueren Untersuchungcn liber d. Extir- 

pation d. Milz. Schmidt's Jahrbuch, Bd., 18G8, cxl, 218. 

401 Schupfer, F. : Sul morbo del Banti (splenomegalia con cirrosi 

del Fegato). Gaz. dcg. Osped., 1908, xxix, 75. 

402 Seiler, F. : Ucber der sogenannten Morbus Banti. Correspbl. 

f. Schweiz. Aertze., 1911, xxxi, 32. 

403 Senator, H. : Ueber Erythrozytosis (Polyzythaemia rubra) 

megalosplenica. Zeitschr. f. klin. Med., 1906, lx, 357. 

404 Senator, H., and Kruse, F. : Ein Fall von idiopathischer Milz- 

schwellung mit Splenektomie. Berl. klin. Woch., 1911, xlviii, 
1217. 

405 Senator, H. : Ueber Anemia splenica mit Ascites (Bantische 

Krankheit). Berl. klin. Woch., 1901, xxxviii, 1145. 
405a Shaw, H. B. : Relation of Splenic Anaemia of Infancy to Other 
Forms of Blood Disease Occurring in Infancy and Childhood. 
Lancet, 1904, ii, 1560. 

406 Sherman, H. C. : Food Products. Macmillan, New York, 

1914. 
407 Sigel: Ueber Anemia Splenica (Morbus Banti) (quoted by 
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408 Silvestri, T. : Milza e Eritropoiesi. Patologica, 1913, v, 145. 

409 Simon: Die Extirpation der Milz. Giessen, 1857. 

410 Sippy, B. W. : Splenic Pseudoleukemia (Anaemia Splenica, Sple- 

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411 Sobotta: Anatomie der Milz. Jena. J. Fischer, 1914, 25 Lief- 

erung des Handbuchs der Anatomie des Menschens (k. v. 

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412 South-Wilson (quoted by Brogsitter, Charite Annalen, 1908, 

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413 Spitta and Mayo (not available, quoted by Simon) : Die Ex- 
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413a Staehelin, R. : Blutuntersuchungen bei einem Fall von Milz- 

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414 Steedly, B. B. : Banti's Disease. Report of an operative case. 

Jour. So. Carol. Med., 1915, xi, 323. 



394 THE SPLEEN AND ANEMIA 

415 v. Stejskae, K. : Ueber hemolytischen Ikterus und iiber das 

Auftreten hemolytischen Vorgange bei diesem und bei perni- 
ciose Anamie. Wien. klin. Woch., 1909, xxii, 661. 

416 Sternberg, C. : Eine 73 Jahrige Frau ohne Milz. Miin. Med. 

Woch., 1903, 1, 92. 

417 Stewart, F. T. : Personal communication to author. 

417a Stillman, R. G. : A Study of von Jaksch's Disease. Am. 
Jour. Med. Sc, 1917, cliii, 218. 

418 Stockman, A., and Greig, E. D. W. : Ingestion and Excretion 

of Iron in Health. Jour. Physiol., 1897, xxi, 55. 

419 Strisower, R., and Goedschmidt, W. : Experimented Beit- 

rage zur Klinik der Milzfunktion. Zeits. f . d. ges. Exp. Med., 
1914, xiv, 237. 

420 v. Stubenrauch: Milz Ruptur und Splenektomie geheilt. Ein 

Jahr spater, Ileus, Laparatomie. Mun. med. Woch., 1911, 
lviii, 1056. 

421 Sturgis, M. G. : Banti's Disease with Report of Successful 

Splenectomy. Bost. Med. and Surg. Jour., 1914, clxx, 832. 

422 Summers, J. E. : (Edema of the Large Intestine, with Local 

Necrosis of Its Wall, following Splenectomy in Banti's Dis- 
ease. Trans. Amer. Surg. Ass'n., 1908, xxvi, 621. 

423 Sutherland, G. A., and Burghard, F. F. : The Treatment of 

Splenic Anaemia by Splenectomy. Lancet, 1910, ii, 1819. 

(Also in discussion of Hutchinson's paper, q. v.) 
424 Taleey, J. E., and Jopson, J. H. : Personal communication to 

the author. 
425 Tansini, I., and Morone, G. : Splenomegalie avec cirrhose 

hepatique en periode ascitique, Splenectomie et operation de 

Talma. Rev. de Chir., 1913, xlviii, 263. 

426 Tarchanoff, J. F. : Ueber die Bildung von Gallenpigment aus 

Blutfarbstoff im Thierkorper. Arch. f. d. Gesamt. Physiol., 
1874, ix, 53. Zur Kenntniss der Gallenfarbstoffbildung, 
ibid., 1874, ix, 329. 

427 Tarachnoff, J., and Swaen, A. : Des globules blancs dans le 



BIBLIOGRAPHY 395 

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42S Tauber, A. : Zur Frage nacli der physiologischen Beziehung 

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429 Taylor, A. E. : Studies in Leukaemia. Contributions from the 

William Pepper Laboratory of Clinical Medicine, 1900, i, 296. 
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431 Thayer, W. S. : Hemolytic Jaundice. Illinois Med. Jour., 

1911, xix, 174. 

432 Thayer, W. S. : Tr. Assn. Am. Phys., 1914, xxix, 489 ; personal 

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433 Thole : Bantische Krankheit im Anschluss an tropische D3* sen- 

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434 Tiedemaxx and Gmelix : Versuche iiber die Verricht. d. Milz, 

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435 Tieestox, W., and Griffix, W. A. : Chronic Family Jaundice. 

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436 Tixier, L. : Ictere d'origine hemolytique. Resistance des 

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437 Tizzoxi, G. : Sulla Riproduzione totale della Milza. Arch. 

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438 Tizzoxi, G. : Studio sperimentale sulla riproduzione parziale 

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439 Tizzoxi, G., and Fileti, M. : Studi pathologici e chimici sulla 

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440 Torraxce, G. : Splenectomy in Banti's Disease with Report of 

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441 Troell, A. : Ligation of Splenic Vessels as a Substitute for 

Splenectomy in Blood Diseases. Ann. Surg., 1916, lxiii, 88. 



396 THE SPLEEN AND ANAEMIA 

442 Truesdale, P. E. : Splenic Ansemia with Report of a Case. 

Bost. Med. and Surg. Jour., 1915, clxxii, 368. 

443 Turk, W. : Die Bedeutung der Milz bei anamischer Zustanden 

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444 Umbeu, F. : Zur Pathologie der Bantischen Milzkrankheit, 
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445 Upcott, H. : Splenic Jaundice : A Contribution to the Surgery 

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446 Urbino, G. : Su di alcuni Casi di Morbo di Banti. Arch. In- 

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447 Van verts, A. : La Splenectomie. These de Paris, 1898. 

448 Vaquez, H. : Sur une forme speciale de cyandse s'accompag- 

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449 Vaquez, H., et Aubertin: Sur 1' Anatomie pathologique de 

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450 Vaquez, H., et Giroux : Ictere chronique acholurique avec sple- 

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451 Veeder : Personal communication to the author. 
452 Verzar, F. : Die Grosse der Milzarbeit. Biochem. Zeitschr., 

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453 Viannay et Tezenas : Un cas de splenectomia pour maladie de 

Banti chez une Feme de 67 ans querison. Lyons Chir., 1911, 
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454 Vincent, B.: Discussion of Syposium on Splenectomy. Jour. 

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455 Virchow, R. : Zur pathologischen Physiologie des Bluts. Die 
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BIBLIOGRAPHY 397 

456 Vogel, K. M. : Theories of the Etiology of Pernicious Anaemia. 
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457 Vogel, K. M. : Personal communication to the author. 

458 Voit, see Herman L. : Handbuch d. Physiol., Leipzig, 1881, vi, 

384. 
459 Vulpian, M. : Examen du sang chez un chien de rate depui 
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460 Vulpius, O. : Beitrage zur Chirurg. u. Phys. der Milz. Beit- 

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461 Warthin, A. S. : The Changes Produced in the Haemolymph- 

glands of the Sheep and Goat by Splenectomy, Hemolytic 
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462 Warthin, A. S. : The Relation of Thrombophlebitis of the Por- 

tal and Splenic Veins to Splenic Anaemia and Banti's Disease. 
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463 Weber, F. P., and Dorner, G. : Four Cases of Congenital 

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464 Weill, O. : Hemolyse locale et hemolyse splenique. Trav. du 

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465 Wells, Spencer : On Excision of Enlarged Spleen, etc. Med. 

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466 v. Wendt: Untersuchungen ueber den Eiweiss-und-Salz-Stoff- 

wechsel beim Menschen. Skand. Arch. Physiol., 1905, xvii, 
211. 

467 Whipham, T. R. C. : Splenomegalic (Hemolytic) Jaundice As- 

sociated with Bile Pigment in the Urine. Report of a Case 
in Which Splenectomy was Performed. Lancet, 1914, ii, 
1194. 

468 Whipple, G. H., and Hooper, C. W. : Hematogenous and 

Obstructive Jaundice, Jour. Exp. Med., 1913, xvii, 593; 
Icterus, Rapid Change of Haemoglobin to Bile Pigment in the 
Circulation Outside the Liver. Jour. Exp. Med., 1913, xvii, 
612. 



398 THE SPLEEN AND ANAEMIA 

469 Widal, F., Abrami, P., and Brule, M. : A propos du role 
hemolytique de la rate normale. Compt. Rend. Soc. de Biol., 
1912, lxxii, 694 ; Le role de la rate dans l'ictere par toluylene- 
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470 Widal, F., Abrami, P., et Brule, M. : Pluralite d'Origine des 

Icteres hemolytique s. Bull, et mem. Soc. Med. des Hop. de 
Paris, 1907, xxiv, 1354. 

471 Widal, F., Abrami, P., arid Brule, M. : Auto-agglutination 

des hematies, dans P ictere hemolytique acquis. Compt. Rend. 
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472 Widal, F., Weissenbach, R. J. : Anemie pernicieuse crypto- 

genetique avec hemolysinhemie et fragilite globulaire alter- 
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250. 

473 Wilbur, R. L., and Addis, T. : Urobilin : Its Clinical Sig- 

nificance. Arch. Int. Med., 1914, xiii, 235 (extensive 
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474 Wilson, C. : Some Cases Showing Hereditary Enlargement of 

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475 Winogradow, K. : Ueber die Veranderungen des Blutes der 

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476 Wood, H. C, Jr.: On the Relations of Leukocythsemia and 

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477 Wolferth, C. C. : Blood Changes in Albino Rats Following 

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477a Wolff: Discussion of Graff's Communication on Splenectomy 

in v. Jaksch's Disease. Verh. d. Deut. Ges. f. Chir., 1908, 

xxxvii, 252. 
478 Wright and Kinnicutt : A New Method of Counting the Blood 

Platelets for Clinical Purposes. Jour. Am. Med. Ass'n., 

1911, lvi, 1457. 



BIBLIOGRAPHY 39!) 

479 Wynter, E., and Bland Sutton, Sir J.: Splenectomy for 
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480 Wynter, W. E., and Bland Sutton, Sir J.: Acholuric Jaun- 
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481 Yates, J. L., Bunting, C. H. and Kristjanson, H. T. : The 
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484 Zanda: Sul rapporto funzionale f ra milza e tiroide. Sperimen- 
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485 Zesas, D. G. : Ueber Extirpation der Milz am Menschen und 
Thiere. Arch. f. klin. Chir., 1883, xxviii, 157 ; also Beitrag 
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486 Ziegler, K. : Die Bantische Krankheit und ihre nosologische 
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der Chir. u. Orthop., 1914, viii, 625. 



INDEX 



Abscess of spleen, 337 
diagnosis, 337 
operative mortality, 339 
surgical treatment of, 337 
splenectomy, 338 
splenotomy, 338 
Accessory spleens in dog, 21 
Alcoholic icterus, 255 
Agglutinins in blood-serum, 280 
Ammonia nitrogen in congenital 
haemolytic jaundice, before and 
after splenectomy, 215 
Anaemia in dogs a factor in in- 
creased haemolytic resist- 
ance, 50 
after ligation of splenic vein, 

125 
after splenectomy, 12 

artificially produced, 100 
methods, 100 
results of experiments, 

101 
repair of, 100 
summary of observa- 
tions, 110 
cause of disturbances of 

metabolism, 201 
causal factor unknown, 111 
diet, influence of, 22, 30, 
34 
raw and cooked, 31 
experimental conclusions, 

33 
general summary of ex- 
perimental studies, 195 
haemorrhagic, 107 

blood repair after, 107 



Anaemia in dogs, after splenec- 
tomy, iron output in- 
creased, 119 
jaundice, influence of, 72 
onset of, 12 
relation to bone-marrow 

changes, 158 
secondary, 12 

caused by haemolytic 

agents, 199 
sodium oleate type, 105 
resistance of red cells in, 
110 
spleen, absence of, a factor 
in chronicity and slow 
repair, 105 
spleen feeding, influence 
of, 97, 198 
caused by haemolytic agents, 
135 
duration of, 137 
toluylenediamine test, 
136 
iron metabolism in, 199 
" splenic," 38 

extract, injections of, in, 
94 
other splenectomized animals, 

22 
in man, after splenectomy, 
duration of, 37 
metabolism, studies of, in, 

228 
nitrogen balance, 231 
pernicious (see pernicious 
anaemia), 265 
icteric form of, 26l 
"splenic/' 241, 242 

401 



402 



INDEX 



Anaemia in man, splenomegaly ac- 
companied by, 241 

Anaemia infantum pseudoleukemia, 
254 

Antihaemolytic property of nor- 
mal dog serum, 47 

Auto-agglutinins in blood-serum, 
test for, 280 

Autolysins, 280 

Bacillus coli, subcutaneous injec- 
tions of, producing spleno- 
megaly, 250 
Banti's disease, 248, 254 
a syndrome, 251 
blood changes, 252 
etiology, 249 

infectious agent, 249 
trauma of spleen, 251 
pathogeneins, 249 
pathology, 253 
protein destruction excessive 

in, 290 
pseudo-, 252 
simulated by syphilis of liver, 

252 
spleen, causative relationship 
of, 253 
enlargement of, nature of, 
252 
splenectomy in, 344 

results of, 330 
symptomatology, 248 
intermediate stage, 249 
pre-ascitic period, 248 
third or ascitic stage, 249 
treatment of splenectomy, 309 
combined with Talma 
operation, 311 
mortality, 310 



Bile, test for, after splenectomy, 54 
changes in, after splenectomy, 
68 
formation from haemoglobin, 
part played by spleen in, 59 
in urine of splenectomized 
animals, 76 
in absence of spleen, 197 

in splenectomized animals, 58 
Bilirubri in duodenal contents, 
quantitative estimate, Schnei- 
der's method, 288 
Blood, regeneration of, time of, 
after destruction by haemo- 
lytic serum, 102 
repair of, in splenectomized 
dog, after haemor- 
rhages, 107 
sodium oleate anaemia, 
107 
of spleen, arterial and venous, 
comparison of, 87 
differential counts, 91 
reliculated or skeined 

red corpuscles, 93 
total haemoglobin, 91 
division of, from liver, re- 
sults of, 200 
splenic extract injections, ef- 
fect of, on, 198 
-cells, red, after splenectomy in 
dogs (see also ery- 
throcytes), 12 
increased resistance 
of, 196 
white, after splenectomy in 
dogs, 17 
differential count, 19 
changes, after Eck fistula, 127 
ligation of splenic vein, 125 



INDEX 



403 



Blood changes, transplantation of 

inferior mesenteric vt in. 

128 

splenic vein to vena cava, 

126 

in man after splenectomy, 34 

crisis, 196, 278, 279, 294, 321 

post-operative, 325 
examinations, in pernicious 
anaemia before and after 
splenectomy, 221 
fat, influence of splenectomy on, 

84 
formation, spleen, absence of, 
unessential to, 198 
power of, in, 88 
splenic extract, influence of, 
on, 93 
experimental tests, 94 

technique, 94 
increase of haemoglo- 
bin content, 97 
leucocytes, 96 
red cell count, 97 
platelets, increase of, after 

splenectomy, 279 
serum, auto-agglutination of, 
280 
changes in, in splenic disease, 

280 
haemolytic power of, test of, 
280 
autolysis, 280 
heterolysis, 280 
isolysis, 280 
technique, 280 
transfusion, 291 

and splenectomy, 347 

comparative results, 294 
in anaemia, effects of, 294 



Blood transfusion, in p< rnicious 
anaemia, 348 
haemolysis and agglutination 
tests, Lindeman's method, 
291 
Minot's method, 293 
selection of donor, 291, 349 
where indicated, 294 
Bone marrow, changes in, after 
splenectomy, 140, 147, 
200 
after varying periods, 

148 
experimental methods, 
142 
conclusions, 162 
results, 144 
histological findings in 
six cases, 150 
discussion, 150 
hyperplasia, 150, 159 
compensatory, 145, 
159, 163 
in femur, 143 
iron storage, 160 
literature, discussion of, 

140 
stimulation theory, 325 
removal of normal organ, 
141, 162 
haemoglobin liberated in, 67 
iron content, 160 
normal, of femur of dog, 145 

blood-cells of, 146 
stimulating effect of normal 
spleen on, 111 
splenic extract injec- 
tions on, 198 
activity, evidences of, in 
splenic disease, 275 



404 



INDEX 



Bone marrow activity, evidences 
of in blood plate- 
lets and leuco- 
cytes, 297 
evidences of by fixed 
smears, 277 
polych.ro- 
matophilia, 279 
by vital staining, 
275 
Bottazzi's haemocatatonistic 

theory, 89 
Bronchitis complicating splenec- 
tomy, 257 

Cholesterin, influence of splenec- 
tomy on, 84 
Cirrhosis of liver, splenectomy in, 

305 
Cobra venom test for haemolysis, 

50 
Congenital haemolytic jaundice, 
metabolism 
studies before 
and after splen- 
ectomy, ammonia 
nitrogen, 215 
creatin excretion, 

215 
fats, 217 

hydrogen ion con- 
centration, 215 
iron elimination, 

217 
nitrogen, 211 
uric acid output, 

214 
urobilin elimination, 

218 
protein, 234 



Control experiments for diversion 
of splenic blood from liver with- 
out splenectomy, 121 

Creatin excretion in congenital 
haemolytic jaundice, before and 
after splenectomy, 215 

Crisis of deglobulization, 314, 329 

Cysts of spleen, 343 

Diet, influence of, on anaemia after 

splenectomy, 22, 196 
normal adequacy of, for splen- 

ectomized dog, 29 
Dislocated spleen, 341 

Eck fistula, experimental method, 
123 
blood changes following, 
127 
conclusions, 129 
effect of, on action of 

haemolytic agents, 130 
jaundice, lessened tendency 

to, after, 138 
splenic blood diverted from 
liver by, 200 
Emotion, effect of, on blood count 

after splenectomy, 14 
Eosinophilia, after splenectomy in 

dogs, 18 
Erythremia (see Polyeythaemia 

rubra), 302 
Erythrocytes, Cabot ring forms, 
278 
resistance of, to haemolytic serum 
injections, 109 
hypotonic salt solution, 67, 
271 
test of, 272 
to saponin, 271 



INDEX 



405 



Erythrocytes, reticulated or 
skeined, 275 
in disease, 276 
in hemolytic jaundice, 276 
in normal human blood, 

276 
nature of, 277 
vital staining test, 275 
Faeces, analysis of, for iron, 115 
Fat metabolism in relation to 

splenectomy, 190 
Fats in congenital haemolytic jaun- 
dice before and after splenec- 
tomy, 217 
Fatty acids and lipoids, influence 

of, in haemolysis, 83 
Fertility of animals, effect of 
splenectomy on, 5 

Gaucher's disease, 243 
acute, 246 
bone-marrow, power of, in 

blood regeneration, 247 
etiology, 246 
pathology, 245 
prognosis, 247 
symptomatology, 246 
blood changes, 247 
enlargement of liver, 247 

spleen, 246 
skin, 247 
splenectomy, 247, 311, 344 
Glenard's disease, 341 

Haemocatatonistic theory of Bot- 

tazzi, 89 
Haemoglobin, changed to bile-pig- 
ment, 63 
course of, liberated in bone- 
marrow, 67 



Hemoglobin, course of, to liver, 
before and after splenec- 
tomy, 197 
degree of retention necessary to 

cause jaundice, 59 
estimations in dogs, after splen- 
ectomy, 14 
free in blood of splenic vein, 89 
in splenic blood-serum, 89, 
92 
test for, 90 
results, 92 
removal of, from blood-serum, 

mechanism of, 62 
saturation point of liver for, 
65, 74 
increased after injections of 

splenic extract, 97 
inj ections of, into portal and gen- 
eral circulation, 68 
persistence of jaun- 
dice after, 70 
results of, 69 
percentages of, eliminated by 
kidneys, 59 
in splenectomized ani- 
mals, 63 
rate of injection a factor in tol- 
eration by liver, 66 
removed by liver, 63 
tests for, after splenectomy, 54 
Haemoglobinaemia in normal ani- 
mals, 59 
Hemoglobinuria, influenced by site 
of haemoglobin injections, 
70 
in normal animals, degree of, 
necessary for escape of 
haemoglobin through kid- 
neys, 59 



406 



INDEX 



Haemoglobinuria in normal ani- 
mals, methods of in- 
vestigation, 59 
results of, 60 
lessened tendency after splenec- 
tomy and use of haemolytic 
agents, 54, 197 
Haemolymph nodes after splenec- 
tomy, 168, 177 
Heterolysins, 280 
Haemolysins in blood-serum, 280 
Haemolysis, fatty acids and lipoids, 
influence of, in, 83 
literature on subj ect, 
83 
salt solution test, 40 
hypotonic, 42 
spleen, absence of, not essential 
to, 198 
influence of, in, 39, 72 
Haemolytic agents, resistance to, 
after Eck fistula, 130 
ligation of splenic vein, 

130 
transplantation of splenic 
vein, 130 
immune serum test, 45 
jaundice, 254 

action of liver on free haemo- 
globin, 264 
acute malignant, 257 
atypical cases, 260 

absence of jaundice, 261 
auto-agglutination test, 256, 

258 
blood count in, 258 
effect of splenectomy on, 264 
findings at autopsy, 265 
cardinal symptoms, 257 



Haemolytic jaundice, congenital 

(see also Congenital 

haemolytic jaundice), 256 

red-blood cell resistance to 

hypotonic salt solution, 

256 

crisis of deglobulization, 329 

differentiation of congenital 

and acquired, 257, 280 
familial, 258 
identity of types, 260 
increase of microcytes and re- 
ticulated red cells, 256 
pathogenesis, 263 

source of increased blood 

destruction in, 264 

red cell resistance decreased, 

due to indirect injury to 

bone-marrow, 264 

simulating pernicious anaemia, 

261 
splenectomy in, 259, 344 

results of, 330 
symptomatology, 255 
blood changes, 255 
splenic enlargement, 255 
treatment of, by splenectomy, 
312, 316 
results of, 313 
surgery of bile-passages, 
297 
power of extracts of spleen, 78 
and other organs, 82 
experiments, results of, 
82 
technique of, 81 
literature on subject, 79 
resistance increased by anaemia, 
50 



INDEX 



407 



Haemolytic serum, effect of, on 
anaemia in unsplenec- 
tomized dog, 74 
splenectomized dogs, 55, 
102 
with normal blood, 75 
injections, jaundice produced 
by, 133 
leucocytes and differential 

blood counts after, 108 
leucocytosis produced by, 

138 
recovery from, in splenec- 
tomized dog, 103 
resistance of red blood-cells 
after, 109 
metabolism, changes in, 
caused by, 234 
splenomegaly, 262 
degenerative, 262 
regenerative, 262 
Haemopsomics, change in, after 

splenectomy, 175 
Haemorrhagic anaemia in splenec- 
tomized dog, blood repair after, 
7 
Hodgkin's disease, 241 
Howell- Jolly bodies, 278 
Hydrogen ion concentration in con- 
genital haemolytic jaundice be- 
fore and after splenectomy, 215 
Hyperplasia of lymph-nodes after 

splenectomy, 169 
Hypersplenism, 265 
Hypotinic salt solution, resistance 
of erythrocytes to, 67, 
271 
tests, 42 



Icterus (sec .Jaundice), 
alcoholic, 255 
lessened tendency to, after 

splenectomy, 54 
pleiochromic, 264 
Intoxication, acute, after feeding 
splenectomized animals with 
sheep spleen, 99 
Iron conservation by the organism, 
113 
elimination of, from the body 
before and after splenec- 
tomy, 113, 116 
in congenital haemolytic jaun- 
dice before and after splen- 
ectomy, 217 
in health and anaemia, 236 
in pernicious anaemia before 
and after splenectomy, 224 
in relation to spleen, 230 
in splenectomized and normal 
dogs, 114 
analysis of faeces, 115 
experiments, 114 
ferrous sulphate 

feeding, 120 
food used in, 116 
results, 116 
increased, after splenectomy, 
due to anaemia, 119 
increased haemolysis, 119 
not dependent directly on 
absence of spleen, 199 
exchange of, influence of splen- 
ectomy on, 235 
indirect effect of, in experi- 
mental splenectomy, 26 



408 



INDEX 



Iron, microchemical tests for, 
after splenectomy, in 
liver, 177 
in lymph-nodes, 177 
content of bone-marrow, 160 
metabolism after splenectomy, 

191 
influence of spleen on, 112 
storage by bone-marrow after 
splenectomy, 160 
Iso-agglutination of blood-serum, 

280 
Isolysius, 280 
von Jaksch's disease, 241, 254 

treatment of, by splenectomy, 
314, 344 

Jaundice after splenectomy, 
anaemia a factor, 73 
influence of increased red-cell 
resistance on, 77 
haemolytic agents, 197 
chronic family, 254 
haemolytic, 254 

congenital (see Congenital 
haemolytic j aundice) , 
202 
metabolism, 227 
influence of anaemia on, 72 
in haemolytic serum experiments, 

133 
lessened tendency to, after 
splenectomy, 72 
persistence of, 77 
vein ligation and blood 
vessel anastomosis, 72 
produced by toluylenediamine 
experiments, 131 

Kupffer's cells, 176 



Leucocyte count after splenectomy 

in dogs, 17 
Leucocytosis, after haemolytic 
serum injections and splen- 
ectomy, 108 
haemolytic agents, 138 
Leukaemia, splenectomy contra- 
indicated, 10, 300, 301 
Lindeman's test for haemolysis and 
agglutination in blood trans- 
fusion, 291 
Liver, changes of, after splenec- 
tomy, 164 
and injection of haemolytic 
serum, 176 
phagocytosis, 176 
blood destruction, 169 
iron, presence of, micro- 
chemical tests 
for, 177 
histologic results, 
178 
compensatory function after 

splenectomy, 180 
diversion of splenic blood from, 

without splenectomy, 121 
saturation point of, for haemo- 
globin, 65, 74 
Lymph-nodes, changes in, after 
splenectomy, 164, 201 
and injections of haemo- 
lytic serum, 172 
blood destruction, 169 
discoloration, 168 
endothelial cells, prolif- 
eration of, 171, 173 
histological, 170 
hyperplasia, 167, 169 



INDEX 



409 



Lymph-nodes, changes in iron, 

microchemical tests 

for presence of, 1 77 

histological results, 

178 

literature, discussion, 

154 
new formation, 167 
phagocytosis, 169, 173 
course of, 175 
time relation of, 173 
red-cell formation, 167 
compensatory formation after 

splenectomy, 180 
in congenital absence of 

spleen, 166 
haemo-, 168, 177 
Lymphocytosis following splenec- 
tomy in dogs, 18 

Malaria, splenectomy in, 307 
Malarial spleen, 339 
Merck's Saponin Purum, 49 
Mesenteric vein, inferior trans- 
plantation of, blood changes 
after, 128 
Metabolism in man after splenec- 
tomy, literature on, 226 
of normal organ, literature, 

229 
iron exchange, 235 
before and after splenectomy, 
literature, 225 
urobilin output, 235 
studies of, 202 

Banti's disease, 225 
haemolytic jaundice, 202 
history of case, 203 
family, 204 
laboratory examina- 
tions, 204 



Metabolism in man, laboratory 
examina- 
tions, methods 
Of study, 209 
blood, 206 
diet, 210 
faeces, 211 
urine, 211 
operation of splen- 
ectomy, 207 
diagnosis, 209 
microscopic ap- 
pearance o f 
spleen, 209 
pathologic de- 
scription, 208 
symptoms, 203 

a t beginning o f 

studies, 205 
results of, 211 

ammonia nitro- 
gen, 215 
creatinin and 

creatin, 215 
fats, 217 
hydrogen ion con- 
centration, 215 
iron elimination, 

217 
nitrogen balance, 

211 
summary of, 219 
uric acid output, 

214 
urobilin elimina- 
tion, 218 
of pernicious anaemia, 
220 
clinical notes, 223 



410 



INDEX 



Metabolism in man, pernicious 
anaemia, results, 
223 
iron elimination, 

224 
nitrogen balance, 

223 
uric acid elimina- 
tion, urobilin, 224 
summary of, 224 
in relation to spleen, 

anaemia, 228 
changes caused by haemo- 
lytic serum, 234 
Metabolism in man in relation to 
spleen, congenital 
haemolytic jaundice, 
227 
iron elimination, 230 
nitrogen balance, 231 
protein destruction, 232 
uric acid elimination, 232 
in relation to splenectomy, ex- 
perimental studies, 
181 
blood examinations, 

191 
body weight increase, 

193 
creatin excretion ab- 
sent, 187 
increased, 189 
discussion of observa- 
tions, 191 
earlier investigations, 181 
faeces, examination 
of, 184 
fat, 184 

fat determina- 
tions, 190 



Metabolism in relation to splenec- 
tomy, experi- 
mental studies, 
greater food re- 
quirement, 193 

influence of 
anaemia o n , 
187, 193, 194 

iron elimination, 

191 
methods, 183 
nitrogen determi- 
nations, 184 
results of, 184 
summary, 194 
urine, analysis of, 
184 
literature, 229 
iron, influence of spleen on, 112 
experimental results, 118 
process of, 112 
nitrogen, in congenital haemo- 
lytic jaundice before and 
after splenectomy, 211 
not affected by splenectomy, 201 
Minot's test for haemolysis and ag- 
glutination in blood transfusion, 
291 

Nephrectomy, a control operation 

for splenectomy in dogs, 29 
Nitrogen metabolism in anaemia, 
literature, 231 
pernicious anaemia before and 

after splenectomy, 223 
in relation to splenectomy, 
181, 184 

Pernicious anaemia, 265 

blood examinations in case of, 
before and after splen- 
ectomy, 221 
transfusion in, 348 



INDEX 



411 



Pernicious anaemia, Hypersplen- 
ism, 265 
iron elimination in case of, 
before and after splenec- 
tomy, 224 
metabolism study in case of, 
before and after splenec- 
tomy, 220 
nitrogen balance in case of, 
before and after splenec- 
tomy, 223 
pathogenesis of, 265 

Eppinger's theory, 267 
remission of, after splenec- 
tomy, 320 
splenectomy in, 265, 344 
effect on metabolism, clini- 
cal notes, 223 
iron, 222 
uric acid, 222 
urobilin, 222 
treatment of, by blood trans- 
fusion, 294 
and splenectomy, 295 
splenectomy, 314 

analysis of results, 318 

influence of age, 322 

degree of anaemia, 

324 
sex, 323 

size o f spleen, 
324 
blood changes, 321 
crisis after, 321 
contra-indications, 327 
aplastic bone-marrow, 

327, 329 
spinal cord symp- 
toms, 327, 329 
effect produced by, 324 
blood crisis, 325 



Pernicious anaemia, treatment of 
splenectomy, ef- 
fect produced by 
bone-m arrow 
stimulation, 825 
erythrocytes, i n - 
creased resist- 
ance of, 326 
indications for, 327 
mortality, 321 
percentage of cures, 321 
results of, 317 
summary of, 328 
time for operation, 329 
value of, 315 
splenic extract injections, 

329 
surgical removal of chronic 
sources of infection, 298 
uric acid elimination in case 
of, before and after splen- 
ectomy, 224 
urobilin elimination in case 
of, before and after splen- 
ectomy, 224 
Phagocytosis, increase of, after 
splenectomy and injection of 
haemolytic serum, 171, 176 
Pheiochromic icterus, 264 
Pneumonia complicating splenec- 
tomy, 357 
Poikilocytosis after splenectomy in 

dogs, 16 
Polychromatophilia, 279 

after splenectomy in dogs, 16 
Polycythemia rubra, 302 
etiology, 304 
haemolysis in, 303 
symptoms, 303 
treatment, 304 

splenectomy contra-indi- 
cated, 304 
X-ray, 305 



412 



INDEX 



Polyglobulia, 314 
Protein metabolism, 233 
Pseudo-Banti's disease, 252 
Pseudoleukemia, " splenic vari- 
ety," 241 

Ptachitische megalospleine, 254 
Red blood-cells increased after in- 
jections of splenic ex- 
tract, 97 
resistance of, after hemo- 
lytic serum injections, 
109 
sodium oleate anaemia, 

11.0 
in relation to splenec- 
tomy, 38 
test by haemolytic 
immune serum, 
45 
hypotonic salt so- 
lution, 42 
saponin, 47 
increased after splenec- 
tomy, 38 
cause of, 50 
conclusions 

of author, 52 
influence on j aun- 
dice, 77 
to cobra venom after 

splenectomy, 50 
to haemolytic agents, in 
wounds and splenec- 
tomized dogs, 199 
t o haemolytic agents, 
summary of observa- 
tions in normal and 
splenectomized ani- 
mals, 110 



Ripper and Schwarzer method, 
modified, of analysis of faeces 
for iron, 115 

Rupture of spleen, 334 

Salt solution test for haemolysis, 40 
Saponin, resistance of erythrocytes 

to, 271 
Saponin test, 47 

Sodium oleate anaemia in splenec- 
tomized animal, 105 
Spleen a factor in haemolysis, 72 
absence of, a factor in chronicity 
of anaemia and slow re- 
pair, 105 
slow repair of sodium oleate 
anaemia, 106 
congenital, 8 

correlation of increased red 
cell resistance and de- 
creased jaundice after 
haemolytic poisons, 111 
essential factor in anaemia, 

196 
influence on haemoglobin and 
jaundice, 59 
nitrogen metabolism, 187 
unessential to blood forma- 
tion, 198 
haemolysis, 198 
arterial and venous blood of, 
comparison of, 87 
differential counts, 91 
reticulated or skeined 

red corpuscles, 93 
total haemoglobin, 91 
changes in, after ligation of 

splenic vein, 124 
dislocated, in man, 341 



INDEX 



U3 



Spleen, effect of, on bone-marrow, 
111 
haemopoietic system, 98 
red cell formation in bone- 
marrow, 97 
enlargement of, 241 

in Gaucher's disease, 246 
experimental studies in animals, 

11 
extirpation of (see Splenec- 
tomy), 3 
anatomical considera- 
tions, 345 
history of, in animal, 3 
in human beings, 6 
feeding of, to splenectomized 
dogs, 97 
influence of, 98 
method, 98 
results, 98 
haemolytic function of, 326 
on haemolysis, 39 
iron metabolism, 12 

experimental results, 118 
regulatory, on blood, 58 
blood destruction and re- 
generation, 87 
early literature, 87 
in relation to 
anaemia, 87 
in Banti's disease, causative re- 
lationship of, 253 
in haemolytic jaundice, 255 
in relation to blood supply of 
liver, 64 
hemoglobinuria and j aundice, 

58 
haemopsonins, 175 



Spleen, in relation to metabolism, 

29 
in man, literature on sub- 
ject (see Metabolism), 
225 
lesions of surgical treatment of, 
333 
abscess, 337 

operative mortality. 

339 
splenectomy, 338 
splenotomy, 338 
cysts, non-parasitic, 343 

parasitic, 343 
gunshot and stab 

wounds, 333 
malarial spleen, 339 
rupture, 334 
mortality, 336 
prognosis, 336 
splenomegaly, 344 
syphilis of spleen, 341 
tuberculous spleen, 340 
tumors, 343 
wandering spleen, 341 
not essential to life, 8 
regeneration of, after extripa- 

tion, 6 
simple hypertrophy of, 242 
site of disintegration of ery- 
throcytes, 66 
spodogenous, 65 
trauma of, cause of Banti's dis- 
ease, 251 
venous blood of, more resistant 
than arterial, litera- 
ture reports, 89 
negative findings, 91 
wandering, ligation of artery in, 
297 



414 



INDEX 



Spleen, X-ray treatment, in splenic 

diseases, 296 
Spleens, accessory, in dog, 21 
Splenectomized animals more re- 
sistant to haemolytic poisons, 38 
Splenectomy and anaemia, relation 
of experi- 
mental studies, 
general sum- 
mary, 195 
the anaemia, 195 
blood crisis, 195 
diet, influence of, 
196 
Splenectomy, in dogs, 11 

accessory spleens, influence 

of, 21 
anaemia following, 12, 144, 
158 
factor in jaundice, 73 
artificially produced, 

summary of observa- 
tions, 110 
blood count emotion, ef- 
fect of, on, 14 
eosinophiles, 18 
erythrocytes, 13 
skeined or reticu- 
lated, 16 
haemoglobin content, 

13 
lymphocytosis, 18 
myelocytes, 20 
poikilocytosis, 16 
polychromatophilia, 

16 
red cells, 13 
white cells, 17 
character of, 15 



Splenectomy in dogs, anaemia fol- 
lowing diet, in- 
fluence of, on, 22, 
24, 30, 34 
food, raw and 

cooked, 31 
iron, 26 

iron-rich food, 23 
experimental conclu- 

sions, 33 
progressive onset of, 12 
stage of beginning re- 
pair, 16 
bile-pigment, changes in, 

after, 68 
bile test, after, 54 
blood changes variable after, 

26 
blood supply of liver after, 

197 
bone-marrow condition of, 

after, 147 
cholesterin increase of, after, 

84 
controlled by previous ne- 
phrectomy, 29 
effects of, 5 

mortality, 6 
first authentic operations on 

dogs, 4 
haemoglobin estimation after, 

14 
haemoglobinuria, after, test 
for, 54 
and jaundice, decreased 
tendency of, after, 54, 
197 
haemopsonins, change in, 

after, 175 
history of, 3 



INDEX 



415 



Splenectomy, iron elimination be- 
fore and after, 116 
experimental results, 

118 
increase of, after, due 
to anaemia, 119 
lessened tendency after, 54 
liver changes after (see 

Liver), 164, 176 
lymph-node changes after 

(see Lymph-nodes), 164 
nature of function lost after, 

121 
in relation to fatty acids and 

cholesterin content, 198 
red cells, resistance of, to 
haemolytic agents 
after, summary of 
observations, 110 
increased after, 38, 
196 
cause, 196 
test by salt solution, 
40 
shaking, 41 
resistance to blood poisons, 

after, 41 
influence of, on blood, 1 1 
blood fat, 84 

on bone-marrow (see Bone- 
marrow), 140, 200 
cholesterin, 84 
on fertility, 5 
general nutrition, 25 
lymph-nodes, 201 
metabolism (see Metabol- 
ism), 23, 181 
on resistance of red blood- 
cells, 39 



Splenectomy, resistance of red 
blood cells to 
haemolytic im- 
mune serum, 
45, 109 
to hypotonic salt so- 
lution, 43 
to saponin, 47 
on weight, 23 
without influence on metabol- 
ism, 201 
Splenectomy in various animals, 
anaemia after, 22 
autopsy findings, 6 
Splenectomy in man, 202 

anaemia, delayed repair of, in 
absence of spleen, 196 
duration of, after, 37 
anatomical considerations, 345 
and blood-transfusion, 347 
comparative results, 294 
blood changes after, 34 
reported cases, 35 
blood platelets increased after, 

279 
supply of portal vein lessened 
after, 198 
choice of time for operation, 329 
complications, of hemorrhage, 
356 
injuries to adjacent viscera, 
357 
contra-indications, 291, 300 
hemorrhagic diathesis, 300 
leukaemia, 10, 300, 301 
polycythaemia rubra, 302 
severe anaemias, 300 
first recorded operations, 6 
for wandering spleen, 342 
history of, 6 



416 



INDEX 



Splenectomy, functional equilib- 
rium after, 234 
abscess of spleen, 338 
in Banti's disease, 344 
in cirrhosis of liver, 300 
cysts of spleen, 343 
in Gaucher's disease, 247, 344 
in hemolytic jaundice, 344 
in v. Jaksch's disease, 344 
in malarial spleen, 339 
in pernicious anaemia, 344 
contra-indications, 327 
curative action denied, 326 
indications for, 327 
summary of results, 328 
in rupture of spleen, 336 
in splenic disease, blood crisis 

following, 278 
splenomegaly, 344 
in syphilis of spleen, 341 
in tuberculous spleen, 340 
in tumors of spleen, 343 
in various blood diseases, mor- 
tality, 309 
influence of, 34 
on metabolism in pernicious 

anaemia, 222 
on urobilin excretion, 287 
iron elimination after, 230 
metabolism studies before and 
after (see Metabolism), 
202 
mortality, 10, 358 
operative risks, 358 
positive indications, 309 

in Banti's disease, 309 
Gaucher's disease, 311 
haemolytic jaundice, 312 
v. Jaksch's disease, 314 
pernicious anaemia, 314 



Splenectomy, possible indications, 
305 
cirrhosis of liver, 305 
malaria, 307 
syphilis, 308 
sequelae of, 357 
bronchitis, 357 
pneumonia, 357 
technique, 350 

closure of splenic space, 355 
control of hemorrhage, 352 
ligation of pedicle, 353 
removal of organ^ 351 
value of, as a therapeutic pro- 
cedure, 299 
Splenic blood, diversion of, from 
liver by Eck fistula, 1 2 1 
by ligation of splenic 

vein, 121 
by transplantation of 

splenic vein, 121 
without splenectomy, 121 
blood crisis following splen- 
ectomy, 278 
diagnostic and prognostic 
methods, 269 
agglutinins and haemo- 
1 y s i n s in blood- 
serum, 280 
blood examinations, 

270 

bone-marrow activity, 

evidences of, 275 

blood platelets 

and leucocytes, 

279 

by fixed smears, 

*277 
by vital staining, 
275 



INDEX 



417 



Splenic disease, history taking, 
269 
hypotonic salt solu- 
tion, 271 
technique, 272 
laboratory tests, 270 
physical examination, 

269 
pol y chroma - 

tophilia, 279 
protein, uric-acid, and 
iron metabolism, 
289 
red blood-cell resist- 
ance, 271 
urobilin excretion, 281 
urobilinogen excretion, 

281 
vital staining, 275 
treatment of, 291 

blood transfusion (see 

Blood transfusion), 291 

medicinal and hygienic 

measures, 296 
surgical, 297 

cauterization and de- 
struction of spleen, 
297 
ligation of blood-vessels 

of spleen, 297 
Schiazzi's " splenoclei- 
sis," 297 
extracts, haemolytic power of, 78 
experiments, results of, 
82 
technique of, 81 
literature on subject, 79 
influence of, on blood forma- 
tion, 93 
27 



Splenic extract, influence of, ex- 
periment- 
al test, 94 
results, 9~> 
technique, 94 
leucocytes increased, 
96 
injections of, in anaemia, 94 
stimulating action on blood, 

198 
on bone-marrow, 198 
vein, ligation of, 121 

circulation after adjust- 
ment of, 125 
blood changes after, 125, 

200 
haemolytic agents, action of, 

after, 130 
jaundice, lessened tendency 

to, after, 138 
method of experiment, 122 
spleen, changes in, 124 
transplantation of, into vena 
cava, 121 
blood changes follow- 
ing, 126 
haemolytic agents, 
action of, after, 130 
jaundice, lessened ten- 
dency to, after, 138 
method of experiment, 
123 
Splenocleisis, 297 
Splenomegaly, 344 
haemolytic, 262 
" idiopathic," 242 
large-celled (see Gaucher's dis- 
ease), 243 
produced by subcutaneous injec- 
tions of Bacillus coli, 250 
with anaemia, 241 



418 



INDEX 



Splenomegaly, classification and 
types, 241 

hepatic cirrhosis (see Banti's 
disease), 248 
Splenopexy in wandering spleen, 

342 
Splenotomy, in abscess of spleen, 

338 
Syphilis of spleen, 341 

splenectomy in, 307 

Test, auto-agglutination in haemo- 
lytic jaundice, 256, 258 
for auto-agglutinins in blood- 
serums, 280 
technique, 280 
for bile after splenectomy, 54 
for effect of spleen feeding to 

splenectomized dogs, 98 
for free haemoglobin in splenic 

blood-serum, 90 
for haemoglobinuria after splen- 
ectomy, 54 
for haemolysis and agglutina- 
tion in blood transfusion, 291 
for hsemolytic power of blood- 
serum, 280 
splenic extracts, 81 
resistance of erythrocytes by 
cobra venom, 50 
for influence of splenic extract 

on blood formation, 94 
for iron metabolism in splenec- 
tomized and normal 
dogs, 114 
with saponin, 47, 271 
for urobilin excretion, Wilbur 
and Addis method 
in stools, 284 
in urine, 282 



Test, hsemolytic serum, 133 

microchemical, for iron in liver 
after splenectomy, 177 
lymph-nodes after splen- 
ectomy, 177 
toluylenediamine for jaundice, 
131 
leucocytosis caused by, 138 
of, resistance of corpuscles, 
with haemolytic immune 
serum, 45 
with hypotonic salt solu- 
tion, 42 
technique, 272 
vital staining, 275 
technique, 275 
Transfusion of blood, 347 
in splenic disease, 291 
Tuberculosis of spleen, 340 
Tumors of spleen, 343 

Uric acid elimination before and 

after splenectomy in 

congenital haemolytic 

jaundice, 214, 233 

in pernicious anaemia, 

224 
in relation to spleen in 
anaemia, 232 
Urobilin elimination after splenec- 
tomy, 287 
in anaemia, 287 
in haemolytic jaundice, 287 
congenital, before and 
after splenectomy, 218 
in pernicious anaemia, before 
and after splenectomy, 224 
in relation to splenectomy, 

235 
in splenic disease, 281 



INDEX 



419 



Urobilin excretion, normal, 287 

quantitative estimation of, in 

duodenal contents, 

Schneider's method, 288 

in stools, Wilbur and Addis 

method, 284 
in urine, Wilbur and Addis 
method, 282 
Urobilinogen elimination, 281 
quantitative estimate of, in duo- 
denal contents, Schneider's 
method, 288 

Vaquez's disease (see Polycyth- 
emia rubra), 302 



Veins, ligation of splenic, I l\ 
conclusions, 120 
transplantation o f , inferior 
mesenteric, blood changes 
after, 128 
portal (Eck fistula), 121 
splenic, 121 

conclusions, 129 
Vital staining, 27a 

Wandering spleen, 341 

White blood-cells, influence on, of 

splenectomy, 108 
Widal's " crises of deglobuliza- 

tion," 258 
Wounds of spleen, 333 



